Transcatheter Caval Valve Implantation for Tricuspid Regurgitation After Single Leaflet Device Attachment

TEE Guiding for T-TEER by Using Multiplanar Reconstructions in a Patient With Previous Surgical Annuloplasty

Transesophageal echocardiographic guidance in tricuspid transcatheter edge-to-edge repair may face limitations in imaging, which are sometimes difficult to overcome and lead to an increased risk of periprocedural complications. We present an imaging vignette describing the usefulness of multiplanar reconstructions by 3-dimensional transesophageal echocardiography in a patient with previously implanted surgical tricuspid annuloplasty ring impeding imaging quality. The procedure was conducted successfully by implanting a single device and reducing tricuspid regurgitation from massive to moderate. Multiplanar reconstructions represent a valuable tool with the possibility for improving safety in tricuspid transcatheter edge-to-edge repair by ameliorated visualization of leaflet insertion and grasping.

Tricuspid transcatheter edge-to-edge repair in a 72-year-old patient with a left ventricular assist device and prior mitral edge-to-edge repair: a case report

Background

We report a case of a 72-year-old patient developing a significant tricuspid regurgitation (TR) 6 years after a left ventricular assist device (LVAD) implantation. The aim of this case is to demonstrate the feasibility of transcatheter edge-to-edge repair (TEER) of the tricuspid valve and the excellent clinical benefit in long-term follow-up in an LVAD patient.

Case summary

Our patient presented with recurrent acute heart failure syndrome. After a fulminant myocarditis in 2005, his previous treatment consisted of cardiac resynchronization therapy, TEER of the mitral valve, and LVAD (HeartMate III) implantation. At that point in time, his TR was only mild to moderate. Due to recurrent hospitalization despite optimized heart failure medication, we decided to treat the patient with a tricuspid TEER. His immediate post-interventional result and 1-year follow-up showed an excellent outcome with only minimal TR on transoesophageal echocardiogram.

Discussion

In general, TR improves after LVAD implantation. However, there are two possible pathophysiological mechanisms, which result in an increasing TR: firstly, supporting LV dysfunction may lead to a leftward shift of the interventricular septum with restriction of the tricuspid leaflets. Secondly, the increase of venous preload with LVAD support may result in an annular dilatation with secondary TR, particularly in patients with pre-existing right ventricular dysfunction. According to the data currently available, the unpredictable course of developing TR necessitates regular clinical examination and echocardiographic investigation. Treatment with TEER appears to be feasible and safe, with excellent 1-year results in patients with previously implanted LVADs.

Comparison of procedural characteristics of percutaneous annuloplasty and edge-to-edge repair for the treatment of severe tricuspid regurgitation

Background

In recent years, new interventional therapies for tricuspid regurgitation (TR) demonstrated their effectiveness in reducing TR severity and improving symptoms. Currently, tricuspid transcatheter edge-to-edge repair (T-TEER) and percutaneous annuloplasty are the most widely used techniques in Europe. In this retrospective study, we compared procedural characteristics and learning curves of both TR devices in a real-world cohort.

Material and methods

Eligible patients with severe to torrential TR underwent either percutaneous annuloplasty or T-TEER as recommended by the local heart team. Patients with combined mitral and tricuspid interventions were excluded from the analysis. The study focused on procedural characteristics, TR reduction and learning curves.

Results

A total of 122 patients underwent either percutaneous annuloplasty (n = 64) or T-TEER (n = 58) with a technical and device success rate of 98% and 97%, respectively. Reasons for technical failure included right coronary artery (RCA) dissection prior to percutaneous annuloplasty, and two single leaflet device attachments (SLDA) during T-TEER implantation. The mean improvement of TR severity was 2.4 ± 0.8 degrees after T-TEER and 2.5 ± 0.8 after percutaneous annuloplasty. T-TEER procedures were shorter in terms of both procedure time and radiation exposure, while percutaneous annuloplasty, although taking longer, showed a significant reduction in procedure time over the course of the analysed period.

Conclusion

In summary, both interventional therapies reduce TR severity by approximately two degrees when used in the appropriate anatomy. The learning curve for annuloplasty group showed a significant decrease of procedure times.