1. Anterior papillary muscle septalization associated with annuloplasty as a new approach to treat functional tricuspid regurgitation Jean-Paul Couetil, MD Henri Mondor Hospital, Creteil, France

2. Tricuspid Valve: A complex anatomy and pathophysiology Tricuspid anatomy - Tricuspid annulus - Subvalvular apparatus (septum + RV free wall) - Tricuspid leaflets Mecanism of FTR - Tricuspid annular dilatation - True prolapsing leaflet area - PMs displacement (RV remodling: conical  spherical/elliptical)

3. PathophysTopilsky et al.iology of Functional TR Left heart disease idiopathic Atrial fibrillation Id-FTR idiopathic Atrial fibrillation Id-FTR RA dysfunction/dilation Tricuspid Annular dilatation Tricuspid regurgitation Tricuspid Annular dilatation Tricuspid regurgitation Pulmonary hypertension PHTN-FTR Pulmonary hypertension PHTN-FTR RV dysfunction/dilation Tricuspid annular dilation Pathophysiology of Functional TR ( 2 Populations) (Topilsky et al.Circ Cardiovasc Imaging, 2012) No Left heart disease

4. Annuloplasty: The treatment of choice to cure FTR? Prevalence of 3+/4+ TR at 5 years n=2’277 patients Navia, et al. Surgical Management of Secondary Tricuspid Valve Regurgitation. J Thorac Cardiovasc Surg 2010: 1-10 Recurrent TR High incidence of recurrent FTR

5. Why do we have recurrent TR? Residual tricuspid regurgitation early after tricuspid valve annuloplasty J Am Soc Echocardiogr 2007;20: 1236-1242 Apical four-chamber view demonstrating techniques used to measure TV deformations

6. What is the state-of-the Art to prevent from recurrent TR? Tricuspid Leaflet Augmentation - Prof. Dreyfus Clover Technique - Prof. Alfieri These techniques Address TR, but are not a pathophysiological approach

7. Areas to Treat Septalization of APM + annuloplasty to reverse the physiopatological FTR mecanism?

8. - Tricuspid valve tethering causing tenting, as a result of outward displacement of PMs in the dilated RV has been reported as a factor decreases the durability of TAP in 12 to 30 % of patients (Fukuda et al. Circulation. 2005; 111:975) - Supported by in vitro study revealing that tricuspid annular dilatation and PMs displacement independently causeTR (Spinner et al. Circulation 2011;124:920) - Valvular changes are linked to specific RV changes, largest basal dilatation, and normal length (RV conical deformation) in the id-FTR versus longest RV elliptical deformation/spherical deformation in PHTN-FTR (Topilsky et al. CIR Cardiovasc Imaging. 2012 5(3):314) Rationale

9. Principles 1) - Based on the new insights of the complex pathophysiology of the FTR 2) - and Successful technique to relocate and reposition PMs in FMR to reduce mitral valve tenting and leaflets tethering 3) - This involves a septalisation of the base of the tricuspid anterior (posterior) papillary muscle

10. What is the septalization principle? Functional Tricuspid Regurgitation Surgical Remodeling of right ventricule Area to Treat To reposition the APM To reallign the subvalvular apparatus In one plane

11. What is the septalization goal? 1)Treat the tenting a)Reduce AB diameter -Bring the tip of APM Closer to annular plane -Bring the tip of APM closer to the septum 2) Remodle the RV a)Reduce RV longitudinal b) And RV transversal diameters

12. How works the septalization +annuloplasty to reverse the mechanism of FTR? FTRAnnuloplasty + APM-S RV remodling APM repositioning

13. Surgical Technique of APM-S 2 pledget-reinforced 4/0 gore-Tex mattress sutures are passed through the base of the anterior papillary muscle close to its free wall insertion. The APM is brought to the septum and the sutures deeply anchored to the septum and firmly attached and tied

14. Surgical Technique of APM-S Video 1.5 MN

15. Surgical correction of the tenting (APM-S + Annuloplasty) and of local leaflets prolapse areas (Neo-Chords) No APM-S = persistent tenting persistent central leak APM-S: good coaptation No more leak

16. Patients Characteristics 1/ Study Population : – 48 patients ( men 21 ; mean age 63 ± 16 ) – Prior cardiac surgery: n=12 ( 9 redux, 2 tridux, 1 quadridux) – NYHAIV :n=2348% III :n=1940% II :n=510% I :n=12%

17. Methods 1/ Population: Study period was from April 2011 to september 2012 Patients referred for tricuspid valve repair according to ESC guidelines Guidelines on the management of valvular heart disease Vahanian et al., Eur Heart J 2007

18. 3/ Echocardiographic Measurements - 2-D TTE standard manner before and after surgery (Vivid7 GE) RVED, RVES,RV fractional area change - 4 chamber view: SL-TV annular diameters, tenting height and area - TR severity assessed by color doppler imaging - TEE per operative before and after procedure - Follow-up TTE at 2, 6 and 12 months

19. 2/ Echocardiographic data – Preoperative LVEF54±13 % LVEF > 55 %n=1940% LVEF 35-55 %n=2654% LVEF < 35%n=36% – Tricuspid annulus diameter:43±7 mm – Tenting area: 2.9±1.6 cm² – Preoperative sPAP: 45±21 mmHg – Preoperative TAPSE 17±5 mm – Tricuspid S wave (DTI)9±3 cm/sec – Preoperative TRIV :n=1940% III :n=1633% II :n=1327% Patients Characteristics

20. Pre-op Echo assessment TTE Apical 4-chamber view Tenting height, Doppler imaging (video clip)

21. 3/ Surgery – Anterior Papillary Muscle Septalisation (APM-S) associated with tricuspid ring implantation (Physio-ring size 26 to 34 mm) – Associated procedures: Mitral valve repairn=2450% Mitral valve replacementn=817% Aortic valve replacementn=613% Yacoub interventionn=12% Coronary artery bypass graftingn=48% Surgical ablation of atrial fibrillationn=48% Ventricular septal defect closuren=24% – (1 post STEMI, 1 congenital) – Extracorporeal duration : 118 ± 37 minutes – Aortic clamping duration: 97 ± 27 minutes Patients Characteristics

22. Per operative TEE 1)Before procedure - Mitral stenosis - Severe FTR: Tenting height ˃ 1.6 cm RV Dilatation 2) After procedure - MVR replacement - Surgical RV remodling - Annuloplasty - APM-S (2 video clips)

23. 4/ Postoperative results – Death < 30 days : n=2 (1 mesenteric ischemia, 1 septic shock) – TTE at the last follow-up: Incidence of tricuspid regurgitation IV : n=0 III : n=12% II : n= 510% 0-I : n = 4288% 98%

24. Summary/Conclusion - TV is a less and less neglected valve - Recent new insights highlighted a complex physiopathology of FTR which is better understood Persisting issues: - Leaflets tenting correction - Post-OP Persistent and reccurent FTR - accurate per op assessment (echo and surgical)

25. Conclusion APM-S + annuloplasty approach allows to/is 1) Correct the tenting 2) Remodle the RV 3) Decrease the incidence of early Post-OP Persistent and reccurent FTR 4) Reliable and reproducible technique 5) Preliminary results, needs to be confirmed