Treatment of Tricuspid Valve Disease in Germany

Tricuspid valve regurgitation is a rare heart disease. In this disease, blood flows back from the right ventricle to the right atrium (tricuspid regurgitation). Pathology can be treated with surgery. In most cases, doctors repair the patient's own valve using annuloplasty or other surgical techniques. Tricuspid valve replacement is performed much less frequently. 

Content

1. Causes
2. Symptoms
3. Diagnostics
4. Should tricuspid valve regurgitation be corrected?
5. Tricuspid valve repair
6. Tricuspid valve replacement surgery
7. Repeated tricuspid valve replacement surgery
8. Why is it worth undergoing treatment in Germany
9. Treatment in Germany with Booking Health

Causes 

In most cases, the valve insufficiency is relative, but not absolute. It is not associated with damage to the heart valve itself, but with dilatation of the right chambers of the heart. In the case of an increase in their volume, the opening between the ventricle and the atrium becomes enlarged. As a result, even a normal valve cannot close it completely, and some of the blood flows back.

The main cause of heart pathology is valve disease. Typically, patients with mitral or aortic valve defects are affected. Clinical trials show that after the correction of these heart valves spontaneous disappearance of tricuspid valve regurgitation is possible. Nonetheless, this does not always happen. Therefore, during heart surgery, doctors usually perform a single-stage tricuspid valve repair.

Rare causes of tricuspid valve disease: 

• Rheumatism.
• Infective endocarditis. 
• Heart tumors. 
• Carcinoid.
• Chest injuries. 
• Diagnostic and therapeutic procedures (biopsy, pacemaker implantation). 

Symptoms 

Tricuspid valve disease is well tolerated by patients. As a rule, a patient does not experience any clinical manifestations for a long time. When symptoms appear, they are largely determined by the underlying pathology, due to which tricuspid valve regurgitation develops, while the underlying pathologies are aortic or mitral valve defects.

As the disease progresses, patients experience impaired heart function and symptoms of right ventricular failure:

• Shortness of breath. 
• Weakness. 
• Palpitations.
• Swelling. 
• Right upper quadrant pain. 
• Enlarged abdomen due to ascites (fluid accumulation).
• Drowsiness, increasing weakness during exercise due to a decreased cardiac output.

When examining, a doctor can see dilated cervical veins. They swell especially when lying down. 

In the area of the liver, pulsation is noted. It does not coincide with the pulsation of the heart – "swing symptom".

Some patients develop severe pulmonary hypertension. In this case, the doctor can palpate the pulsation of the pulmonary artery.

A complication of right ventricular heart failure due to damage to the tricuspid valve sometimes becomes liver fibrosis. The doctor may palpate an enlarged liver with a sharp and tight edge.

Diagnostics 

To diagnose tricuspid valve disease, echocardiography (heart ultrasound scanning) is used. The doctor assesses the degree of expansion of the annulus fibrosus, the size and function of the right ventricle. It is possible not only to state the defect, but also to establish the severity, identify the cause of the development of tricuspid valve regurgitation, and detect concomitant heart defects.

Additional diagnostic examinations: 

• ECG to assess heart rate.
• Cardiac MRI with insufficient information content of ultrasound.
• Cardiac catheterization (only if indicated, when it is necessary to measure the pressure in the pulmonary artery). 

Should tricuspid valve regurgitation be corrected? 

In the middle of the twentieth century, tricuspid valve regurgitation was divided into organic and functional. The form of a defect that developed as a result of damage to the valve apparatus itself, for example, with endocarditis, was considered organic. But the majority of patients are people with functional impairment, which can independently regress.

In the 60s of the twentieth century, tricuspid valve regurgitation was treated only with a conservative method. It was believed that the defect would disappear on its own after reconstruction or replacement of other valves. Doctors adhered to such recommendations until the 80s of the last century. Then clinical studies showed that the defect does not always regress. More aggressive surgical tactics began to be applied. Now, when performing surgery to eliminate valve defects in the left half of the heart, doctors simultaneously correct tricuspid insufficiency.

According to modern European recommendations, it is customary to perform surgical correction if the defect is moderate or severe, accompanied by pulmonary hypertension or expansion of the annulus fibrosus up to 4 cm.

In Europe, even moderate tricuspid valve disease can be immediately eliminated if doctors perform an operation to correct another heart defect. A single-stage tricuspid valve repair does not increase surgical risks, but reduces the risk of disease progression.

In most cases, mild tricuspid valve regurgitation is benign. Symptoms do not appear, the disease does not go into a severe stage, and after correction of the underlying pathology, the insufficiency can regress. Nonetheless, in 25% of cases this does not happen. After mitral or aortic valve repair or replacement, tricuspid regurgitation progresses to a severe degree instead of disappearing. As a result, the patient needs a second open-heart surgery. But it is more risky to operate on a patient repeatedly – according to different clinical studies, the mortality rate is 15-35%. In addition, non-fatal complications are common. These require additional treatment or worsen the quality of life. Therefore, cardiac surgeons also simultaneously correct tricuspid defects with either mitral or aortic one, despite the fact that the risk of its progression is relatively low.

Tricuspid valve repair 

The preference is always given to the repair of the patient's own tricuspid valve. This is due to the fact that the results of plastic surgery are better, and there is a less risk of the need for repeated operations.

Annuloplasty is mostly performed. This is an operation to strengthen the annulus fibrosus. Less commonly, doctors perform interventions on the valve flaps or chords, which are the threads that hold the flaps. Tricuspid valve repair options are as follows:

• Suture annuloplasty. The cardiac surgeon sutures the support ring. There are many modifications to this treatment. Surgical techniques may differ depending on the location and method of suturing. In general, suture options for annuloplasty are considered unreliable. After their use, tricuspid valve regurgitation may recur after several years. Therefore, the technique is used less and less and can be suitable mainly for moderate tricuspid valve disease.
• Among the suture plastic repair procedures, de Vega plastic surgery is most often performed. It preserves the anatomy and flexibility of the annulus fibrosus. The advantages are the absence of foreign materials in the heart, the low cost of the operation and its short duration.
• Support ring annuloplasty (remodeling annuloplasty). The surgical procedure involves the use of either rigid or soft rings. The preference is given to the soft ones. The support rings narrow the valve opening while maintaining valve movement. In addition, deformities of the annulus fibrosus can be eliminated, which provides more reliable results compared to suture annuloplasty.
• The tricuspid valve has three leaflets: anterior, posterior, and septal. When annuloplasty is performed with a support ring, the doctor fixes it with sutures in the area of the anterior and posterior flaps. In the projection of the septal leaflet, sutures are not applied, since during this procedure, damage to the atrioventricular junction is possible, which will entail the development of the heart block.
• Leaflet patch repair. It is used in case of injury in order to increase the leaflet area. This type of defect is rare. This is usually the result of a previous infection, rheumatism, or chest injury. The doctor eliminates the defect by performing plastic surgery with the patient's own pericardium or synthetic materials. If the leaflet comes off, the doctor can sew it on. If there is a neoplasm, it will be resected. Annuloplasty (strengthening of the annulus fibrosus) is usually performed simultaneously with the valve plastic surgery.
• Operations on the chordae tendineae. The doctor can move them or shorten them. Sometimes prosthetic repair can be performed. The operation aims to establish artificial chordae tendineae. 

Tricuspid valve replacement surgery 

Tricuspid valve replacement surgery can rarely be performed. This operation is resorted to only if the regurgitation is absolute but not relative, the valve is destroyed and cannot be repaired. As a rule, such situations are a consequence of the previously experienced endocarditis – infectious or rheumatic.

There are biological and mechanical prostheses. Mechanical ones are better because they last longer. Sometimes they are prescribed for young patients.

But still, in the overwhelming majority of cases, biological prostheses are implanted in the position of the tricuspid valve. This is due to the fact that blood clots are more often formed in the right half of the heart, and thromboembolic complications are possible. After the implantation of a mechanical artificial valve, the patient needs lifelong anticoagulant therapy. Moreover, the doses of drugs used are high, so the risk of bleeding increases. At the same time, blood clots can form even while taking anticoagulants.

After the implantation of biological prostheses, anticoagulants are taken not for life, but in a limited course. Blood clots on these valves are rare, but they have another drawback: gradually degeneration occurs, and dysfunction of the artificial valve develops. Biological valves are short-lived. In patients with high life expectancy, repeated prosthesis replacement surgery is inevitable.

Repeated tricuspid valve replacement surgery 

Repeated surgeries on the tricuspid valve can be performed in case of dysfunction (wear) of the biological prosthesis. These are usually open-heart operations.

Some hospitals in Germany perform minimally invasive TVIV (tricuspid valve-in-valve) interventions. A new artificial valve is delivered to the heart through an incision in the leg. The opening of the old valve is expanded with a balloon and another valve is implanted over it.

The operation takes about 2 hours. It is minimally traumatic. There is almost no blood loss – usually it does not exceed 100 ml. Chest incisions are not made because the doctor gains access to the heart through the common femoral vein. Therefore, the patient does not have to recover for a long time after this operation.

So far, the technique is not a standard treatment. The experience of its application even in the best hospitals in Europe is small. It remains to be seen in clinical trials whether this procedure is as effective as repeated open tricuspid valve replacement surgery. Currently, the TVIV operation is used as a method of treating patients with high surgical risks. That is, in those who cannot undergo open surgery due to the threat of severe complications and death.

Why is it worth undergoing treatment in Germany 

A huge number of patients from all over the world undergo treatment in Germany, where a high level of clinical medicine, well-equipped hospitals and world-renowned cardiac surgeons await them. There are several reasons why it is worth undergoing tricuspid valve regurgitation treatment in one of the hospitals in Germany:

• The preference is always given to tricuspid valve repair, rather than its replacement, since in this case there is a lower risk that a second operation will be required in the future.
• Annuloplasty involves the use of support rings rather than suture techniques, as this surgical option is more effective.
• With replacement surgery, cardiac surgeons in Germany implant biological prostheses in the position of the tricuspid valve in order to reduce the risk of thrombosis and hemorrhagic complications of anticoagulant therapy.
• The latest types of biological prostheses with a long service life are used.
• In case of wear of the prosthesis, it is possible to implant another artificial valve using a minimally invasive method – through the vessels in the leg, but not through a large chest incision.
• Simultaneous correction of several heart defects is possible.
• If necessary, simultaneous surgical treatment of several diseases can be carried out at once, for example, the doctor performs plastic repair of the heart valves and coronary artery bypass grafting.

Treatment in Germany with Booking Health

To undergo treatment in one of the hospitals in Germany, please use the services of Booking Health. On our website, you can see the cost of treatment in different clinics, compare prices and book a medical care program at a favourable price. Tricuspid valve regurgitation treatment in Germany will be easier and faster for you, and the cost of treatment will be lower.

Leave your request on our website. Our employee will contact you and advise you about treatment in Germany. Booking Health will take care of the organization of your trip. We will provide the following benefits for you:

• We will select a hospital in Germany, whose doctors specialize in the treatment of tricuspid valve diseases.
• We will help you overcome the language barrier, establish communication with your attending physician.
• We will reduce the waiting time for the start of the medical care program and book a doctor's appointment on the most suitable dates.
• We will reduce the price. The cost of treatment in a hospital in Germany will be lower due to the lack of additional coefficients for foreign patients.
• We will take care of all organizational issues: documents for entering the country, transfer from the airport, hotel, interpreter, etc.
• We will prepare a program and translate medical documents. You do not have to repeat the previously performed diagnostic procedures.
• We will provide communication with a hospital in Germany after the completion of the program.
• We will organize additional diagnostic examinations and treatment in a hospital in Germany, if necessary.
• We will buy medicines abroad and forward them to your native country.
• We will help you keep in touch with the hospital and the doctor after completing the program.

You will receive treatment from the best doctors in the world. We will take care of all organizational issues, and you will only have to focus on restoring your health.

Authors: Dr. Nadezhda Ivanisova, Dr. Farrukh Ahmed