Transcatheter Tricuspid Valve Replacement

Funktionelle Trikuspidalklappeninsuffizienz – Klinische und echokardiografische Parameter für die Auswahl von Patient und Verfahren

Die sekundäre Trikuspidalklappeninsuffizienz (TI) ist ein häufiger Klappenfehler und führt oft erst in fortgeschrittenen Stadien zu Symptomen. Die Prognose von betroffenen Patienten ist eingeschränkt und die perioperative Letalität bei konventioneller Chirurgie der isolierten TI hoch, sodass kathetergestützte Verfahren einen enormen technischen Fortschritt in den letzten Jahren gemacht haben. Zudem hat die anatomische und auch klinische Patientenauswahl an Bedeutung gewonnen, da sowohl in der klinischen Präsentation als auch in der individuellen Anatomie der Trikuspidalklappe eine große Variabilität herrscht. Klinisch ist bzw. sind insbesondere das Vorhandensein einer (präkapillären) pulmonalen Hypertonie oder fortgeschrittene Stadien des Rechtsherz-Remodelings mit einer reduzierten Prognose nach kathetergestützten Eingriffen assoziiert. Zudem sind relevante Komorbiditäten und funktionelle Fitness/Gebrechlichkeit zu evaluieren. Echokardiografisch ist die funktionelle TI durch eine Anulus- und/oder rechtsventrikuläre bzw. rechtsatriale Dilatation gekennzeichnet, welche zu Koaptationsdefekten der Trikuspidalklappensegel und einer Zügelung der Segel („Tethering“) führen können. Die Ausprägung dieser Parameter sowie die Anulusgröße, der Schweregrad der TI und das Vorhandensein von transvalvulären Sonden im Bezug zur Trikuspidalklappe sind die wichtigsten echokardiografischen Parameter, die in die Patientenauswahl einfließen müssen.

Transcatheter valve implantation for degenerated tricuspid bioprosthesis and failed tricuspid ring

Background

Transcatheter tricuspid valve-in-valve (TViV) and valve in-ring (TViR) implantation have become a viable therapy for a failed tricuspid bioprosthesis. Here we report short (thirty days) and long (one-year) term clinical outcomes of ten patients who underwent TViV at our institution.

Methods

The electronic databases of New York Presbyterian Columbia Medical Center were retrospectively reviewed for cases of transcatheter tricuspid valve replacement (TViV or TViR). Between 2012 and 2019, data from ten patients who underwent TViV were collected. The primary safety outcome was procedure-related adverse events, including clinically evident cardiac perforation, new pericardial effusion and sustained ventricular arrhythmia. The primary efficacy endpoint was defined as successful valve deployment with total (paravalvular or intravalvular) tricuspid regurgitation (TR) estimated as mild or less. Results are descriptive in nature.

Results

A total of ten patients who underwent TViV were included in the study. Of them, 40% presented with isolated tricuspid bioprosthetic stenosis (TS), 20% with isolated TR and 40% with mixed TS and TR. All patients were treated with the SAPIEN valve (first generation, XT, or Sapien 3). The TViV procedure was successful in all patients, and no immediate post-replacement paravalvular leak (PVL) or intra-procedural complications were reported. The primary safety and efficacy endpoints were met in all patients. At thirty-days, all patients were alive and reported significant improvements in symptoms and functional status.

Conclusions

Transcatheter tricuspid valve implantation is a safe and effective therapy for degenerative tricuspid bioprosthesis.

Interventional Strategies in Cancer-induced Cardiovascular Disease

PURPOSE OF REVIEW

To highlight the range of illnesses and procedures that the interventional onco-cardiologists face in their daily practice, along with the recent additions to anti-cancer therapies and their related cardiotoxicity.

RECENT FINDINGS

Immune checkpoint inhibitors (ICI) are not devoid of cardiotoxicity as thought earlier and lead to an increased incidence of myocarditis. Transcatheter valve replacement has been shown to be a safer alternative to surgical replacement in cancer patients. Interventional onco-cardiology is a novel field that addresses cardiovascular diseases in the setting of cancer. Traditionally excluding cancer patients from clinical trials has led to a dearth of information needed to tackle cardiac conditions like Takotsubo cardiomyopathy, malignant pericardial effusions, and radiation-induced vascular diseases encountered either exclusively or predominantly in this high-risk population. This review discusses the various treatment options available in the interventional armamentarium with a particular focus on ICI-myocarditis and transcatheter aortic valve replacement in cancer patients.

Topographical anatomy of the right atrial appendage vestibule and its isthmuses

INTRODUCTION

The right atrial appendage (RAA) vestibule is an area located in the right atrium between the RAA orifice and the right atrioventricular valve annulus and may be a target for invasive transcatheter procedures.

METHODS AND RESULTS

We examined 200 autopsied human hearts. Three isthmuses (an inferior, a middle, and a superior isthmus) were detected. The average length of the vestibule was 67.4 ± 10.1 mm. Crevices and diverticula were observed within the vestibule in 15.3% of specimens. The isthmuses had varying heights: superior: 14.0 ± 3.4 mm, middle: 11.2 ± 3.1 mm, and inferior: 10.1 ± 2.7 mm (p < .001). The superior isthmus had the thickest atrial wall (at midlevel: 16.7 ± 5.6 mm), the middle isthmus had the second thickest wall (13.5 ± 4.2 mm), and the inferior isthmus had the thinnest wall (9.3 ± 3.0 mm; p < .001). This same pattern was observed when analyzing the thickness of the adipose layer (superior isthmus had a thickness of 15.4 ± 5.6 mm, middle: 11.7 ± 4.1 mm and inferior: 7.1 ± 3.1 mm; p < .001). The average myocardial thickness did not vary between isthmuses (superior isthmus: 1.3 ± 0.5 mm, middle isthmus: 1.8 ± 0.8 mm, inferior isthmus: 1.6 ± 0.5 mm; p > .05). Within each isthmus, there were variations in the thickness of the entire atrial wall and of the adipose layer. These were thickest near the valve annulus and thinnest near the RAA orifice (p < .001). The thickness of the myocardial layer followed an inverse trend (p < .001).

CONCLUSIONS

This study was the first to describe the detailed topographical anatomy of the RAA vestibule and that of its adjoining isthmuses. The substantial variability in the structure and dimensions of the RAA isthmuses may play a role in planning interventions within this anatomic region.

Mitral and Tricuspid Transcatheter Interventions Current Indications and Future Directions

Valvular heart disease is responsible for a high rate of morbidity and mortality, especially in the elderly population. With the emergence of new transcatheter treatment options, the therapeutic spectrum for patients with valvular heart disease has considerably expanded during the past years. Interventional treatment of the mitral and tricuspid valve requires an individualized and versatile approach owing to the different etiologies of valvular dysfunction and the complex anatomy of the atrioventricular valves. This article aims to review recent developments, summarize the evidence, indications and limitations of the available systems, and provide a glimpse into the future of transcatheter interventions for the treatment of mitral and tricuspid valve disease.

Imaging and Patient Selection for Transcatheter Tricuspid Valve Interventions

With the emergence of transcatheter solutions for the treatment of tricuspid regurgitation (TR) increased attention has been directed to the once neglected tricuspid valve (TV) complex. Recent studies have highlighted new aspects of valve anatomy and TR etiology. The assessment of valve morphology along with quantification of regurgitation severity and RV function pose several challenges to cardiac imagers guiding transcatheter valve procedures. This review article aims to give an overview over the role of modern imaging modalities during assessment and treatment of the TV.

Transcatheter valve-in-valve implantation for degenerated surgical bioprostheses

Transcatheter valve-in-valve (VIV) procedures are less invasive than re-do open heart surgery, and have proven relatively safe and effective. In large multicentre registries morbidity and mortality risks are generally lower than with surgery, and improvement in quality of life can be profound. Outcomes continue to improve with advances in transcatheter heart valve (THV) technology, techniques, and expertise. However specific concerns remain; including residual stenosis, coronary obstruction, left ventricular outflow tract obstruction, and thrombosis. The unknown durability is a concern in patients with the potential for longevity. Transcatheter VIV procedures will likely increasingly be favoured over reoperation when bioprosthetic heart valves fail, particularly when surgical risks are high.

Transcatheter Tricuspid Valve Replacement: Principles and Design

Tricuspid regurgitation (TR) may affect as much as 65-85% of the population with the prevalence of moderate-to-severe TR in the United States reported at greater than 1.6 million. However, only 8,000 tricuspid valve operations are performed annually in the United States. As severe TR is associated with poor outcomes, there is an unmet clinical need for surgical or percutaneous transcatheter based treatment of TR. Over the last two decades there have been significant developments in percutaneous transcatheter based therapies for valvular disease. However, this progress has not been mirrored for the tricuspid valve until recently; we are now at a cross-roads of new transcatheter devices becoming available for treatment of TR. In this review, we discuss the principles of performing transcatheter tricuspid valve replacement, analyze the devices that can be utilized and outline the challenges related to this procedure.