Tratamientos percutáneos de la valvulopatía tricuspídea: una nueva esperanza para la válvula «olvidada»

Tricuspid valve repair and replacement for infective endocarditis

Infective endocarditis represents a challenging and life-threatening clinical condition affecting native and prosthetic heart valves, endocardium, and implanted cardiac devices. Right-sided infective endocarditis account for approximately 5-10% of all infective endocarditis and are often associated with intravenous drug use, intracardiac devices, central venous catheters, and congenital heart disease. The tricuspid valve is involved in 90% of right-side infective endocarditis. The primary treatment of tricuspid valve infective endocarditis is based on long-term intravenous antibiotics. When surgery is required, different interventions have been proposed, ranging from valvectomy to various types of valve repair to complete replacement of the valve. Percutaneous removal of vegetations using the AngioVac system has also been proposed in these patients. The aim of this narrative review is to provide an overview of the current surgical options and to discuss the results of the different surgical strategies in patients with tricuspid valve infective endocarditis.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12055-023-01650-0.

Transcatheter interventions for severe tricuspid regurgitation: a literature review

The prevalence of tricuspid regurgitation (TR) increases with age, affecting 65%-85% of adults. Primary TR is caused by a congenital or acquired abnormality of the tricuspid valve apparatus (leaflets, chordae, papillary muscles, or annulus). Secondary TR is due to insufficient coaptation from dilation of tricuspid valve annulus due to the right ventricle (RV) or right atrium (RA) remodeling and increased RV pressures. Isolated TR is without increased RV pressures and is associated with atrial fibrillation. Mild TR is a benign disease. Moderate to severe tricuspid regurgitation has independently been associated with increased mortality. Most of these patients are treated medically due to poor outcomes with surgical repair of isolated TR. The in-hospital mortality rate is 8.8%, and the median length of stay in hospital is 11 days resulting in higher healthcare costs. Even if the patients undergo surgical repair or replacement, available data do not show improvement in survival. With a more detailed understanding of the complex anatomy and physiology of the tricuspid valve and significant complications from untreated tricuspid valve disease, the approach to the management of TR has shifted from a conservative approach to a process of prevention and intervention. In the past decade, transcatheter tricuspid valve interventions and tricuspid annuloplasty rings have been developed, contributing to decreased mortality from surgical repair. Transcatheter tricuspid valve intervention techniques have improved survival, quality of life, and reduced heart failure rehospitalization. This review summarizes normal anatomy, types of TR, etiology and different mechanisms of TR, echocardiographic assessment of the severe TR, and highlights various percutaneous transcatheter techniques for tricuspid valve repair.

Quantitative assessment of tricuspid regurgitation using right and left ventricular stroke volumes obtained from tomographic equilibrium radionuclide ventriculography

BACKGROUND

Quantitative assessment of valve regurgitation using volumetric method by comparing right and left ventricular stroke volumes is still under investigations.

AIMS

To investigate the accuracy of tomographic equilibrium radionuclide ventriculography (t-ERV) for the quantification of tricuspid regurgitation (TR).

METHODS AND RESULTS

Sixty-one patients (44 men; mean age 59 ± 12 years) who underwent both t-ERV and transthoracic echocardiography (TTE) studies within 2 weeks for right ventricular systolic function assessment were eligible for inclusion. A sub-group of 22 patients underwent both t-ERV and CMR. Patients with mitral/aortic regurgitation by TTE were excluded of the study. TR regurgitant volume (RVol) was calculated using the proximal isovelocity surface area (PISA) method from TTE and the volumetric method (right ventricular stroke volume minus left ventricular stroke volume) from t-ERV. There was a significant correlation between RVol as assess by ERV and by TTE (R = 0.95, P < 0.0001). Intraclass correlation coefficient between TTE and ERV for TR quantification was 0.95 (P < 0.0001). Among patients who underwent CMR, the correlation between RVol obtained by TTE and by t-ERV and CMR were R = 0.81 and R = 0.75, respectively (all P < 0.0001).

CONCLUSION

TR assessment using the t-ERV correlates well with PISA from TTE in patients referred for right ventricular systolic function assessment.

Bloody tricuspid stenosis: case report of an uncommon cause of haemoptysis

Background

Haemoptysis is usually caused by pulmonary and infectious diseases. In few cases, it has a cardiac cause, such as pulmonary embolism or mitral valve stenosis. Haemoptysis may be an uncommon symptom of prosthetic valve dysfunction, being related to elevated right heart pressures.

Case summary

A 22-year-old woman from sub-Saharan Africa known for a triple valve replacement was hospitalized for dyspnoea and haemoptysis. A careful clinical evaluation excluded the most common causes of haemoptysis. Transthoracic echocardiogram showed normal biventricular function, normally functioning mechanical prosthetic aortic and mitral valves, and the biological tricuspid prosthesis showed an increased transvalvular gradient. Contrast chest computed tomography scan excluded pulmonary embolism and mechanical valve obstruction, but revealed marked systemic venous hypertension. Right heart catheterization confirmed increased right heart pressures and severe bioprosthetic tricuspid valve stenosis. The patient underwent a successful percutaneous tricuspid valve-in-valve replacement, with complete resolution of symptoms.

Discussion

The increase in venous pressures due to bioprosthetic tricuspid stenosis caused veno-venous shunts: blood from the lower body was drained into the superior vena cava via the azygos vein. Increased pressure in the latter affected pressure in bronchial veins and arteries, leading to haemoptysis. Cardiac surgical reinterventions are associated with worse outcomes and higher mortality rates. Management of a degenerated prosthetic tricuspid valve is challenging and requires a multidisciplinary assessment. Transcatheter tricuspid valve replacement is becoming a feasible option in patients with prosthetic dysfunction. Based on evidence to date, tricuspid valve-in-valve replacement appears to be a safe, feasible, and effective alternative in selected young patients.

Design and evaluation of the crimping of a hooked self-expandable caval valve stent for the treatment of tricuspid regurgitation

To design a hooked self-expandable caval valve stent and determine the best crimping scenario for its percutaneous implantation in the Superior and Inferior Vena Cava (SVC & IVC) for the treatment of tricuspid regurgitation (TR). A hooked, Nitinol based stent design was modeled using SOLIDWORKS and finite element analysis (FEA) was carried out using ABAQUS. The Nitinol material used in this study was modeled in ABAQUS as superelastic-plastic. Two cases were simulated. In case A, the stent model was crimped to 18 F by compressing the stent main body and then: (i) bending both the proximal and distal hooks; (ii) straightening the proximal hooks and bending the distal hooks. In case B, the stent model was crimped to 18 F by: (i) bending the proximal and distal hooks and then compressing the stent main body; (ii) straightening the proximal hooks and bending the distal hooks and then compressing the stent main body. The maximum strain after crimping was used to evaluate the best crimping scenario. Hook straightening produced strains of 10.7% and 10.96% as opposed to 12.6% and 13.0% produced by hook bending. From comparison of results of both cases simulated, it was found that straightening the hooks gave lower strain and thus was the best crimping procedure. The analysis performed in this paper may help understand the critical issue of crimpability of the new stent design. The best crimping scenario can be found based on finite element modeling and simulation. Identifying the best crimping way will also help the design team to optimize the delivery system that will eventually be used to deploy this caval valve stent.

Tricuspid Valve Annular Mechanics: Interactions with and Implications for Transcatheter Devices

In the interventional treatment of tricuspid valve regurgitation, the majority of prosthetic devices interact with or are implanted to the tricuspid valve annulus. For new transcatheter technologies, there exists a growing body of clinical experience, literature, and professional discourse related to the difficulties in delivering, securing, and sustaining the function of these devices within the dynamic tricuspid annulus. Many of the difficulties arise from circumstances not encountered in open-heart surgery, namely; a non-arrested heart, indirect visualization, and a reliance on non-suture-based methods. These challenges require the application of procedural techniques or system designs to account for tricuspid annular motion, forces, and underlying tissue strength. Improved knowledge in these interactions will support the goals of improving device systems, their procedures, and patient outcomes. This review aims to describe current concepts of tricuspid annular mechanics, key device and procedural implications, and highlight current knowledge gaps for future consideration.