Transcatheter bi-caval valve implantation (CAVI) significantly improves cardiac output: mechanistic insights following CardioMEMS® and TricValve® implantation

A comprehensive overview of surgical and transcatheter therapies to treat tricuspid regurgitation in patients with heart failure

PURPOSE OF REVIEW

The unique pathophysiologic considerations of severe tricuspid regurgitation (TR) have led to advancements in surgical and transcatheter treatments. The purpose of this review is to highlight the current surgical and transcatheter tricuspid valve interventions (TTVI) to functional TR.

RECENT FINDINGS

Surgical repair with ring annuloplasty consistently demonstrates better outcomes than surgical replacement or other repair approaches. However, surgical uptake of TR correction remains relatively low, and operative mortality rates are still high owing to multiple comorbidities and advanced tricuspid valve disease/right ventricular dysfunction at time of referral. Pivotal trials for tricuspid transcatheter edge-to-edge repair (T-TEER) and transcatheter TV replacement (TTVR) indicate improved quality of life compared to medical therapy alone for high-surgical-risk patients with severe symptomatic TR. Trials are underway to assess caval valve implantation (CAVI), which holds hope for many severe TR patients who are not ideal candidates for T-TEER or orthotopic TTVR. Peri-procedural optimization of right ventricular function remains critical to promote both device success and patient outcomes.

SUMMARY

Clinical outcomes after surgical TV intervention are poor, often due to intervening late in the disease course of TR. TTVI covers a treatment gap for patients deemed inoperable or high-surgical-risk, but earlier referral for TV interventions is still important prior to patients developing multiorgan dysfunction from chronic untreated TR.

Bicaval TricValve Implantation in Patients With Severe Symptomatic Tricuspid Regurgitation: 1-Year Follow-Up Outcomes

BACKGROUND

Several orthotopic transcatheter strategies have been developed to treat severe tricuspid regurgitation (TR); however, many patients are deemed unsuitable. Caval valve implantation with the TricValve system addresses this unmet need.

OBJECTIVES

This study sought to determine the impact of TricValve on systemic congestion and quality of life (QOL) at 1 year.

METHODS

The TRICUS (Safety and Efficacy of the TricValve® Transcatheter Bicaval Valves System in the Superior and Inferior Vena Cava in Patients With Severe Tricuspid Regurgitation) and TRICUS EURO studies were prospective, nonblinded, nonrandomized, single-arm trials representing the early-in-man experience of the TricValve system in NYHA functional class III or IV severe TR patients, optimally medicated and ineligible for open heart surgery, with significant caval backflow. The primary endpoint was QOL metrics and functional status. The 1-year results of the combined cohort are described here.

RESULTS

Forty-four patients were included. Mean age was 76.2 ± 7.5 years, 81.0% were women, and the TRISCORE (risk score model for isolated tricuspid valve surgery) was 5.3 ± 1.3. Clinical improvement at 1 year was achieved in 42 (95.5%) patients, measured by (at least 1 of) an increase in ≥15 points from baseline in 12-item Kansas City Cardiomyopathy Questionnaire score, improvement to NYHA functional class to I or II, or an increase ≥40 m in the 6-minute walk test. There were 3 (6.8%) deaths at 1-year follow-up (1 cardiovascular), and the heart failure rehospitalization rate was 29.5%. Stent fracture, conduction system disturbances, or clinically significant leaflet thrombosis were not detected. Abolished hepatic vein backflow was achieved and persisted in 63.8% of the patients, contributing towards a reduction in congestive symptoms, N-terminal pro-B-type natriuretic peptide levels (P = 0.032), and diuretic treatment.

CONCLUSIONS

Caval valve implantation with the TricValve system associated with meaningful 1-year clinical improvements in terms of QOL along with relatively low mortality rates. (TRICUS Study - Safety and Efficacy of the TricValve® Device; NCT03723239).