Indications, Limitations, and Development of Tricuspid Valve Interventions in Adults

TriClip G4: A game-changer for tricuspid valve regurgitation treatment

Tricuspid valve regurgitation, or TR, is a difficult-to-manage condition. In addition to EVOQUE, percutaneous annuloplasty, and surgical repair, the TriClip G4 system has been added to the interventional therapeutic choices for TR. Recently, the Food and Drug Administration (FDA) approved the use of the TriClip G4 device to treat patients with symptomatic, severe TR who have received optimal medication therapy but are at intermediate or higher risk of surgery. This review attempts to offer a thorough examination of the procedural features, learning curves, results of the device and compares the TriClip G4 system to other interventional therapies for TR. TriClip G4 has shown to have promising results in pivotal clinical trials, be cost-effective, and improve the quality of life of patients. Furthermore, it has its unique advantages against other conventional techniques and devices.

Transcatheter Intervention for Management of Tricuspid Regurgitation Using TriClip

Severe tricuspid regurgitation (TR) is an underrated, common pathology that affects over 70 million individuals worldwide. Traditionally, TR has been managed with diuretic therapies without any significant mortality benefit. The underlying cause of TR can be primary, coming from structural issues with tricuspid valve and more commonly secondary, arising from conditions affecting the right ventricle or the pulmonary circulation. Management of TR has seen few improvements until recently. Traditionally, valve replacement and surgical repair were the therapeutic options available. Tricuspid valve is a complex cardiac structure with many technical challenges for surgical intervention. Transcatheter valve interventions have proven to be safe and effective novel therapeutic options for severe TR, which reduce the severity of TR with associated improvement in quality of life. In this review, we will provide an overview of the management of severe TR utilizing transcatheter edge-to-edge repair with the TriClip device (Abbott, Santa Clara, CA).

Which lesions are not amenable to tricuspid clipping?

PURPOSE OF REVIEW

Tricuspid transcatheter edge-to-edge repair (T-TEER) has emerged as a well tolerated and effective therapeutic option for many patients with symptomatic severe tricuspid regurgitation at prohibitive surgical risk. However, there remain several important limitations to clip-based technology in the context of other rapidly emerging percutaneous treatment options for tricuspid regurgitation.

RECENT FINDINGS

Tricuspid lesions pose unique challenges to treatment with the current toolbox of transcatheter clip-based technologies. This review will explore key issues related to patient factors, anatomical factors, and imaging factors that may render lesions to be unsuitable for treatment with T-TEER.

SUMMARY

Selection for T-TEER must include a detailed clinical evaluation in the context of a 'heart team' approach involving multiple subspecialists, with screening for patient/lesion characteristics that make T-TEER suboptimal with current clip-based technologies. Future directions for research include patient-specific 3D modeling techniques, leaflet grasping techniques, clip deployment strategies, and personalized device sizing to increase the spectrum of lesions that may be treated with T-TEER within the context of other emerging transcatheter treatment options.

Transcatheter valvular therapies in patients with left ventricular assist devices

Aortic, mitral and tricuspid valve regurgitation are commonly encountered in patients with continuous-flow left ventricular assist devices (CF-LVADs). These valvular heart conditions either develop prior to CF-LVAD implantation or are induced by the pump itself. They can all have significant detrimental effects on patients' survival and quality of life. With the improved durability of CF-LVADs and the overall rise in their volume of implants, an increasing number of patients will likely require a valvular heart intervention at some point during CF-LVAD therapy. However, these patients are often considered poor reoperative candidates. In this context, percutaneous approaches have emerged as an attractive "off-label" option for this patient population. Recent data show promising results, with high device success rates and rapid symptomatic improvements. However, the occurrence of distinct complications such as device migration, valve thrombosis or hemolysis remain of concern. In this review, we will present the pathophysiology of valvular heart disease in the setting of CF-LVAD support to help us understand the underlying rationale of these potential complications. We will then outline the current recommendations for the management of valvular heart disease in patients with CF-LVAD and discuss their limitations. Lastly, we will summarize the evidence related to transcatheter heart valve interventions in this patient population.