Concept: Tricuspid insufficiency
Due to the increased life expectancy and continual improvements in cardiological treatment options, diseases of the tricuspid valve, in particular tricuspid valve insufficiency will become increasingly more recognized as an interventional target. While tricuspid stenosis is rare and can be effectively treated with balloon valvuloplasty, no effective transcatheter approach to tricuspid regurgitation (TR) has yet been established. As the tricuspid annulus is a complex and highly dynamic structure that offers little resistance, orthotopic long-term fixation of transcatheter valves with the current techniques is challenging and has not yet been performed in human patients. Alternative treatment concepts include transcatheter caval valve implantation (CAVI) to address the regurgitation of blood into the caval veins, which has resulted in hemodynamic improvement and is currently undergoing further clinical investigation. Other interventional treatment concepts are aimed at tricuspid valve repair, e.g. by annular plication with the Mitralign™ device or the TriCinch™ system. In the medium-term it can be assumed that percutaneous systems and therapy options will become available for these indications whereby the functional and prognostic effects of these treatment procedures will be corroborated in the appropriate patient groups by corresponding studies.
We describe a minimally invasive heart surgery application of the EinsteinVision 2.0 3D high-definition endoscopic system (Aesculap AG, Tuttlingen, Germany) in an 81-year-old man with severe tricuspid valve insufficiency. Fourteen years ago, he underwent a Ross procedure followed by a DDD pacemaker implantation 4 years later for tachy-brady-syndrome. His biventricular function was normal. We recommended minimally invasive tricuspid valve repair. The application of the aformentioned endoscopic system was simple, and the impressive 3D depth view offered an easy and precise manipulation through a minimal thoracotomy incision, avoiding the need for a rib spreading retractor.
A 33-year-old woman who had received a diagnosis of tricuspid valve endocarditis caused by MRSA was evaluated for replacement of the tricuspid valve. Videos show giant systolic pulsations during jugular venous examination and severe tricuspid regurgitation during transthoracic ECG.
Severe tricuspid regurgitation is associated with poor prognosis; however, there are limited class 1 indications for intervention, and high-surgical risk patients may go untreated. We report the first-in-human successful transcatheter tricuspid valve repair for severe tricuspid regurgitation.
Although associated with left heart pathologies, functional tricuspid regurgitation (FTR) is often left untreated during left heart surgery. Hence, owing to its degenerative character, reoperation is often needed, encompassing an impressive (25% to 35%) mortality rate. Thus transcatheter approaches to FTR are raising great interest.
The aim of this study was to investigate the procedural feasibility and short-term durability of the transcatheter tricuspid valve edge-to-edge repair technique in highly symptomatic patients with severe tricuspid regurgitation (TR).
Background -Current surgical and medical treatment options for severe tricuspid regurgitation (TR) are limited and additional interventional approaches are required. In the present observational study, the safety and feasibility of transcatheter repair of chronic severe TR with the MitraClip system were evaluated. In addition, the effects on clinical symptoms were assessed. Methods -Patients with heart failure symptoms and severe TR on optimal medical treatment were treated with the MitraClip system. Safety, defined as periprocedural adverse events such as death, myocardial infarction, stroke, or cardiac tamponade, and feasibility, defined as successful implantation of one or more MitraClip devices and reduction of TR by at least one grade, were evaluated before discharge and after 30 days. In addition, functional outcome, defined as changes in NYHA class and 6 minutes walking distance, were assessed. Results -We included 64 consecutive patients (mean age 76.6±10 years) deemed unsuitable for surgery who underwent MitraClip treatment for chronic, severe TR for compassionate use. Functional TR was present in 88%. 22 patients were also treated with the MitraClip system for mitral regurgitation as a combined procedure. The degree of TR was severe or massive in 88% of patients before the procedure. The MitraClip device was successfully implanted in the tricuspid valve in 97% of the cases. After the procedure, TR was reduced by at least one grade in 91% of the patients, thereof 4% that were reduced from massive to severe. In a total of 13% of patients TR remained severe after the procedure. Significant reductions in effective regurgitant orifice area (0.9±0.3cm(2)vs.0.4±0.2cm(2); p<0.001), vena contracta width (1.1±0.5cm vs. 0.6±0.3cm; p=0.001) and regurgitant volume (57.2±12.8ml/beat vs. 30.8±6.9ml/beat; p<0.001) were observed. No intraprocedural deaths, cardiac tamponade, emergency surgery, stroke, myocardial infarction or major vascular complications occurred. There were 3 (5%) in-hospital deaths. NYHA class was significantly improved (p<0.001) and 6 minutes walking distance increased significantly (165.9±102.5m vs. 193.5±115.9m; p=0.007). Conclusions -Transcatheter treatment of TR with the MitraClip system seems to be safe and feasible in this cohort of preselected patients. Initial efficacy analysis showed encouraging reduction of TR, which may potentially result in improved clinical outcomes.
The SCOUT (Percutaneous Tricuspid Valve Annuloplasty System for Symptomatic Chronic Functional Tricuspid Regurgitation) trial is a prospective, single-arm, multicenter, early feasibility study of a novel transcatheter device to plicate the tricuspid annulus (TA) and reduce tricuspid regurgitation (TR).
Tricuspid regurgitation (TR) is the most common lesion of the tricuspid valve (TV). Mild TR is common and usually is benign. However, moderate or severe TR can lead to irreversible myocardial damage and adverse outcomes. Despite these findings, few patients with significant TR undergo surgery. The treatment of functional (secondary) TR in particular remains controversial because of high rates of residual or recurrent TR and poor outcomes following surgical intervention. Traditional teaching that functional TR resolves on its own if the underlying disease is successfully treated has proven to be incorrect. This review aims to clarify management of TR by describing the anatomy, pathophysiology, diagnosis, and treatment of TR, including the eventual possibility of percutaneous TV therapy.
Isolated tricuspid valve surgery is associated with high morbidity and mortality, especially in patients with prior cardiac surgery. The transcatheter Forma Repair System (Edwards Lifesciences, Irvine, California) is designed to provide a surface for native leaflet coaptation to reduce tricuspid regurgitation (TR) by occupying the regurgitant orifice area.