Tricuspid Clip in Tricuspid Regurgitation

Feb 21, 2020   |  Gilbert Hin-Lung Tang, MD, MSc, MBA, FACC

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National Heart Valve Disease Awareness DayAs part of American Heart Month, and in recognition of National Heart Valve Disease Awareness Day on Feb. 22, the ACC Interventional Section has written a series of articles focused on valvular heart disease, including the role of imaging modalities, emerging trends in transcatheter mitral valve replacement and tricuspid valve repair, and perspectives on novel applications of transcatheter aortic valve replacement. See the entire series on the Invasive CV Angiography and Intervention and Valvular Heart Disease Clinical Topic Collections. For patient resources, check out CardioSmart's Heart Valve Disease Hub and new "Heart Valve Disease Treatment with TAVR" infographic.

Severe tricuspid regurgitation (TR), whether symptomatic or asymptomatic, is predictive of poor survival if left untreated. Medical therapy, consisting mostly of diuretics, is of limited efficacy. Clinical sequelae, including right heart dysfunction, peripheral edema, and liver congestion, confer a poor quality of life and poor prognosis. Surgical tricuspid repair and replacement have significant mortality and morbidity risks due to patient comorbidities and poor right heart function.

Transcatheter tricuspid valve repair is an emerging alternative to medical therapy and surgery to manage patients with symptomatic severe TR. Several technologies are currently in clinical trials, including edge-to-edge repair, annuloplasty repair, and de novo replacement (Figure 1). The MitraClip device (Abbott Structural Heart; Santa Clara, CA) has been used to repair the tricuspid valve in an off-label manner in over 1,000 cases worldwide with excellent safety and good efficacy, as evidenced by multicenter retrospective studies and the TriValve Registry. The TRILUMINATE (Evaluation of Treatment With Abbott Transcatheter Clip Repair System in Patients With Moderate or Greater Tricuspid Regurgitation) global feasibility study, consisting of sites from the European Union and United States, evaluated transcatheter tricuspid valve repair using the TriClip system (Abbott Structural Heart; Santa Clara, CA). The 1-year outcomes, presented at the 2019 PCR London Valves Annual Meeting, showed excellent safety and efficacy of the TriClip system in terms of TR reduction, low mortality, improvement in quality of life, and right atrial and ventricular modeling (Figures 2-3).1

Figure 1: Transcatheter Tricuspid Therapy Landscape

Figure 1
Printed with permission from the author, Dr. Azeem Latib.

Figure 2

Figure 2
At 1 year, the TRILUMINATE early feasibility study showed sustained reduction in TR after TriClip repair. Slide presented by Dr. Georg Nickenig at the 2019 PCR London Valves Annual Meeting, London, UK.1

Figure 3

Figure 3
At 1 year, the TRILUMINATE early feasibility study showed positive right atrial and right ventricular remodeling after TriClip repair. Slide presented by Dr. Georg Nickenig at the 2019 PCR London Valves Annual Meeting, London, UK.1

Imaging the tricuspid valve can be challenging. Transesophageal echocardiography (TEE) is the primary modality used to optimize leaflet grasping and assessment of insertion (Figure 4). Intracardiac echocardiography (ICE) can be a valuable complementary imaging tool to confirm leaflet insertion (Figure 5).2 The TRILUMINATE Pivotal Trial is currently ongoing, randomizing patients with symptomatic severe TR to medical therapy or TriClip or utilizing TriClip as a treatment arm if the TR can be reduced by only one grade in severity.

Figure 4

Figure 4
Three-dimensional multiview on TEE demonstrated optimal grasping views for tricuspid edge-to-edge repair with the MitraClip system. Printed with permission from the author, Dr. Gilbert Tang.

Figure 5

Figure 5
Three-dimensional multiview on ICE complements those obtained on TEE and can help confirm optimal tricuspid leaflet grasping with the MitraClip system. Printed with permission from the author, Dr. Gilbert Tang.

References

  1. Nickenig G, on behalf of the TRILUMINATE investigators. Percutaneous edge-to-edge repair for tricuspid regurgitation: Initial 1-year outcomes from the TRILUMINATE clinical trial. Presented at PCR London Valves 2019; November 18, 2019.
  2. Tang GH, Yakubov SJ, Sanchez Soto CE. Four-Dimensional Intracardiac Echocardiography in Transcatheter Tricuspid Valve Repair With the MitraClip System. JACC Cardiovasc Imaging 2020;Jan 9:[Epub ahead of print].

Clinical Topics: Arrhythmias and Clinical EP, Cardiac Surgery, Heart Failure and Cardiomyopathies, Noninvasive Imaging, Valvular Heart Disease, Atrial Fibrillation/Supraventricular Arrhythmias, Cardiac Surgery and Arrhythmias, Cardiac Surgery and Heart Failure, Cardiac Surgery and VHD, Echocardiography/Ultrasound

Keywords: Heart Valve Diseases, Tricuspid Valve Insufficiency, Tricuspid Valve, Echocardiography, Transesophageal, Ventricular Remodeling, Retrospective Studies, Diuretics, Feasibility Studies, Quality of Life, Atrial Fibrillation, Treatment Outcome, Mitral Valve, Heart Ventricles, Registries, Surgical Instruments, Edema, Polymerase Chain Reaction, Longitudinal Studies


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