Author + information
- Joachim Schofer, MD, PhD∗ (, )
- Claudia Tiburtius, MD,
- Christoph Hammerstingl, MD,
- Per-Olof Dickhaut, MD,
- Julian Witt, MD,
- Lorenz Hansen, MD,
- Friedrich-Christian Riess, MD, PhD and
- Klaudija Bijuklic, MD
- ↵∗Albertinen Heart Center, Süntelstrasse 11a, 22457 Hamburg, Germany
There is increasing evidence that severe tricuspid regurgitation (TR) is associated with a poor prognosis. Recently, less invasive transcatheter tricuspid repair technologies are emerging as alternative therapeutic options for high surgical risk patients. One percutaneous mitral valve repair system (MitraClip, Abbott Vascular, Santa Clara, California) has demonstrated safety and long-term clinical benefit. Very similar to functional mitral regurgitation (MR), TR is mainly due to ventricular enlargement, annulus dilation, and loss of leaflet coaptation. Thus, percutaneous mitral valve repair therapy might potentially also be applied for TR.
A 77-year-old woman presented with increasing dyspnea and signs of right heart failure in New York Heart Association functional class III. Within the past 6 months, she had several hospital admissions despite intensive diuretic therapy. Her medical history included severe chronic obstructive pulmonary disease and atrial fibrillation. Echocardiography revealed severe TR. The right ventricle was enlarged (43 mm) with preserved ventricular function (tricuspid annular plane systolic excursion 27 mm). Systolic pulmonary artery pressure was 50 mm Hg, and the left ventricular ejection fraction was normal with moderate MR.
Based on the heart team’s discussion, the surgical risk for this patient was unacceptably high. The patient gave her written informed consent for the procedure on the basis of a compassionate use of the device.
The procedure was performed with the patient under general anesthesia with access from the right femoral vein. The 24-F steerable guide catheter was positioned over a stiff guidewire into the right atrium. The guide catheter was then slightly pulled back, and the tip was flexed. Thereafter, the clip was advanced forward until the bullet nose protruded from the tip of the guide catheter. The clip was positioned perpendicular to the tricuspid valve by anterior movement and bending of the guide catheter. Using deep transgastric mid- and deep esophageal 2- and 3-dimensional transesophageal echocardiography views, the appropriate clip arm orientation was adjusted, the clip was advanced into the right ventricle slightly under the leaflets, which were then captured.
After implantation of a single clip, TR was reduced from severe to mild (Figure 1). At discharge, the patient’s symptoms significantly improved, transthoracic echocardiography demonstrated a stable clip position and sustained reduction of TR.
We report the first transfemoral implantation of the MitraClip in a tricuspid valve with severe functional TR that resulted in a significant TR reduction. Therapeutic options for those patients are limited. Therefore, less invasive and safer therapeutic solutions are needed for this ever-growing patient population. A few transcatheter-based treatment options for TR are currently under evaluation. Laule et al. (1) reported on 3 patients with single or dual implantation with the SAPIEN XT prosthesis (Edwards Lifesciences, Irvine, California) for severe TR. This approach does not address TR itself, but may reduce the regurgitation of blood into the vena cava. With improvement in 2- and 3-dimensional TEE, advanced imaging of the tricuspid valve became possible. Targeting malcoaptation, the results of 7 high-risk patients with severe TR who received the Forma Repair System (Edwards Lifesciences) were recently published (2).
We reported on the first-in-humans transcatheter tricuspid valve repair by using a pledgeted suture (Mitralign System, Mitralign Inc., Tewksbury, Massachusetts) (3).
Our patient had no shelf to use for pledget placement, but the right atrium was large enough to steer the guide catheter and a coaptation was sufficient to grasp the leaflets in the area of significant TR. Therefore, she was deemed a suitable candidate for the percutaneous mitral valve repair procedure. Theoretically, this procedure can be performed from the internal jugular or femoral vein. We chose the femoral vein as the access site because it gives more stability to the guide catheter and facilitates steering maneuvers.
When considering the percutaneous mitral valve repair system for tricuspid valve repair, several requirements must be met: 1) a large right atrium for guide catheter steering; 2) sufficient coaptation to get enough tissue for the (first) clip; 3) good echocardiographic visibility, which is crucial and might be a problem in the presence of valve prosthesis or severe calcification of the mitral annulus; 4) avoiding deep diving into or extensive movements of the clip in the right ventricle to prevent chordae rupture.
This is the first description of a new interventional approach for transfemoral tricuspid repair using the percutaneous mitral valve repair system. Larger studies are required to confirm the feasibility, safety, and efficacy of the percutaneous mitral valve repair therapy in patients with severe TR.
Please note: Dr. Hammerstingl has received honoraria from Abbott, Mitralign, and Valtech for serving as a proctor. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- American College of Cardiology Foundation
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