Transcatheter Treatment and Tricuspid Regurgitation

Rodés-Cabau J, Hahn RT, Latib A, et al.
Transcatheter Therapies for Treating Tricuspid Regurgitation. J Am Coll Cardiol 2016;67:1829-1845.

The following are 10 key points to remember from this review on transcatheter therapies for treating tricuspid regurgitation (TR):

  1. The majority (75%) of TR is secondary, and most commonly arises from right ventricular (RV) annular dilatation following RV pressure or volume overload.
  2. Tricuspid valve (TV) surgery most commonly occurs as part of other cardiac surgeries. Hospital mortality for isolated TR has been reported from 2-9.8% with risk factors including measures of RV size and function and preoperative hemoglobin, bilirubin, and creatinine levels.
  3. Secondary TR presents a challenge for transcatheter therapies because of an enlarged (at times >40 mm) and nonplanar structure of the TV annulus as well as lack of calcium.
  4. European and American Heart Association/American College of Cardiology guidelines suggest using the diastolic septolateral dimension from the transthoracic apical four-chamber view as a criterion for intervening, with a diastolic dimension of ≥40 mm (or >21 mm/m2) indicating severe tricuspid annular dilatation.
  5. Several transcatheter approaches have been proposed for severe TR. These include caval valve implantation, a device aimed at improving TV leaflet coaptation by occupying the regurgitant orifice area (FORMA device), and devices dedicated to decreasing tricuspid annulus dimensions in order to reduce TR severity (Mitralign and TriCinch devices).
  6. Caval valve implantation addresses regurgitation into the caval veins, but does not directly address TR. Implantation of a valve in the inferior vena cava (IVC) may be limited by large diameter of the IVC and proximity of the right atrium and hepatic veins.
  7. The FORMA device aims to decrease TR by enhancing leaflet coaptation with a spacer device (balloon filled with foam), which is anchored in the RV apex. Seven patients have been treated with the device, with reduction in TR to moderate in all patients.
  8. The Mitralign device aims to decrease TR by decreasing annular dilatation. The device converts an incompetent TV into a competent bicuspid valve by plication of both the anterior and posterior tricuspid annulus.
  9. The TriCinch system is an additional tricuspid annuloplasty device in which tension is applied to the tricuspid annulus by a corkscrew anchor placed in the anteroposterior TV annulus connected to a stent in the IVC using a Dacron band. Eight patients have received this device thus far.
  10. None of the current transcatheter alternatives mimic complete ring annuloplasty, which has been shown to be the most efficient surgical technique for functional TR.

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