Transcatheter Treatments of the Tricuspid Valve: Key Points

Maisano F, Hahn R, Sorajja P, Praz F, Lurz P.
Transcatheter Treatments of the Tricuspid Valve: Current Status and Perspectives. Eur Heart J 2024;45:876-894.

The following are key points to remember from a state-of-the-art review about the current status and perspectives on transcatheter treatment of the tricuspid valve (TV):

  1. This review summarizes current knowledge related to mechanistic understanding, diagnostic evaluation, and transcatheter treatment options for the “no-more-forgotten” TV. The TV has long been a marker of prognosis for left-sided heart disease and pulmonary hypertension. More recently, registry data have highlighted the prevalence and adverse clinical impact of isolated tricuspid regurgitation (TR) on prognosis and mortality. TR is no longer considered a benign condition and patients with at least moderate TR should be followed closely.
  2. In addition to the variability of valve morphology, mechanisms of regurgitation, hemodynamics, and clinical presentation seem to have prognostic relevance. Right heart function plays a major role in risk assessment with signs of right ventricular (RV) failure indicating later stages of disease progression. Several risk models are available to predict all-cause mortality with or without therapy and should be utilized to identify patients who would benefit from invasive treatment. Surgery can play a role in earlier stages of disease, while transcatheter therapies are available for patients at high risk and in later stages of disease. Transcatheter tricuspid valve intervention (TTVI) seems to be an effective and safe intervention in select patients; however; clinical benefits beyond improved quality of life remain to be demonstrated.
  3. A comprehensive evaluation of the TV should be performed by transthoracic echocardiography (TTE) to quantify the severity and etiology of TR, assess left ventricular and RV size and function, and the presence of concomitant disease of other valves or pulmonary hypertension. Transesophageal echocardiography (TEE) should be performed in all patients considered for TTVI to further assess leaflet morphology and function (i.e., mobility, tethering, and coaptation gaps), TR jet number, size and location, annular morphology and size, and subvalvular anatomy (i.e., location and density of chordae, location/height of papillary muscles). Computed tomography (CT) allows comprehensive anatomical evaluation of the TV complex, right ventricle, and right coronary artery. In addition, CT is essential for preprocedural planning of device delivery. Intraprocedural imaging relies on TEE and fluoroscopy. More recently, 3D intracardiac echo imaging has been used successfully when TEE is suboptimal.
  4. The PCR Tricuspid focus group revised the TR classification, which now includes “Primary” (abnormal valve structure), “Secondary” (valve dysfunction is secondary to atrial or ventricular remodeling with normal valve anatomy), and “Cardiac Implantable Electronic Device (CIED)-related.”
  5. Patients with severe symptomatic isolated TR should undergo disease staging using imaging, clinical status, and biomarkers. For low-risk patients, surgery should be considered. TRI-SCORE is a scoring method used to predict hospital mortality in patients undergoing surgery for isolated TR. For high-risk patients with advanced disease, palliation should be recommended. For high-risk patients with a favorable prognosis, TTVI should be considered. Decision regarding type of TTVI is predicated on multi-modality imaging (TTE, TEE, CT, cardiac magnetic resonance [CMR]) and right heart catheterization.
  6. TTVI can be achieved with leaflet approximation devices (tricuspid transcatheter edge-to-edge repair (T-TEER) with annuloplasty, or with other devices including spacers (devices filling the coaptation gap) and chordal approximation devices. T-TEER remains the most commonly performed repair procedure. T-TEER addresses TR by a combination of leaflet approximation at the site of regurgitation and indirect annular reduction. TriClip is a dedicated system for T-TEER, while PASCAL can be used for both atrioventricular valve interventions.
  7. While T-TEER is the most performed intervention, annuloplasty replicates the most common surgical repair procedure, with the advantage of leaving all alternative options open. Cardioband was the first TTVI device implanted in Europe. Despite its strong rationale, however, it is implanted only in very experienced centers because of the complexity of the procedure and the potential risk of coronary lesions.
  8. Transcatheter tricuspid valve replacement (TTVR) has been performed off-label as valve-in-valve and valve-in-ring procedures. There are several dedicated tricuspid replacement devices under clinical investigation currently.
  9. Caval valve implantation (CAVI) has been attempted to protect organs from venous hypertension and reduce backflow-associated TR. The exact role of CAVI in the field needs to be further developed, considering its simplicity and reproducibility, with the inherent limitation of an intervention that does not address the culprit lesion.
  10. The decision regarding choice of transcatheter therapy for primary TR is predicated on several factors including leaflet anatomy, annular dimensions, and mechanism of regurgitation. Leaflet prolapse, flail or papillary muscle rupture can be considered for T-TEER.
  11. TR in patients with a CIED requires careful consideration. Determining CIED interaction with tricuspid apparatus is key prior to choosing intervention. T-TEER, and annuloplasty are not contraindicated and the presence of a CIED seems to have no impact on outcomes.
  12. For secondary TR, treatment options are more nuanced depending on atrial- or ventricular-based TR. For ventricular-based secondary TR, understanding RV function and RV/pulmonary artery coupling will determine the utility of therapy. For atrial-based secondary TR, in addition to therapy for atrial fibrillation, the decision regarding T-TEER, transcatheter tricuspid annuloplasty, TTVR, or CAVI is based on annulus size, coaptation gap, and depth.
  13. Future directions include identifying novel diagnostic and patient selection tools, identifying new imaging techniques to improve procedural training and outcomes, and continuing to improve on current devices and technology. Given the complexity of right heart disease and TR, a one-size-fits-all approach is unlikely to succeed. Collaboration between cardiology specialties and a patient-centered approach will be needed to improve outcomes.

Clinical Topics: Invasive Cardiovascular Angiography and Intervention

Keywords: Tricuspid Valve, Tricuspid Valve Insufficiency

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