Transcatheter treatment of severe tricuspid regurgitation using the edge-to-edge repair technique

Transcatheter Edge-to-Edge Repair in Valvular Heart Disease: A Comprehensive Exploration of Equipment, Efficacy, Gender, Racial, and Socioeconomic Disparities, and Future Prospects

The 2 primary components of valvular heart disease are mitral regurgitation (MR) and tricuspid regurgitation (TR). Transcatheter edge-to-edge repair (TEER) is an advanced, minimally invasive procedure that has recently displayed encouraging outcomes in the treatment of these pathologies. TEER offers a nonsurgical alternative for individuals diagnosed with conditions deemed to be high-risk surgical candidates. Currently, the TEER procedure employs devices such as MitraCLIP and TriCLIP, as well as innovative PASCAL (transcatheter valve repair system used for mitral and tricuspid valve repair) and FORMA (repair system used for tricuspid valve repair) repair systems. In the COAPT (Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients with Functional Mitral Regurgitation) trial enrolling 614 patients to test the efficacy of TEER in MR, a significant reduction in hospitalization due to heart failure was observed at 24 months in the MitraClip + guideline-directed medical therapy (GDMT) group (35.8%) than in the GDMT-alone group (67.9%), HR, 0.53; P < 0.001, lower rate of all-cause mortality at 29.1% compared with 46.1% (P < 0.001), lower risk of cerebrovascular events (P = 0.001), and lower mortality due to cardiovascular events (P < 0.001). In another trial, patients with moderate TR or greater than New York Heart Association Class II or higher underwent TEER using the TriClip for the management of TR. The outcomes were encouraging, with 86% of patients showing a reduction in TR severity of at least one grade. As the technology and research surrounding TEER continue to progress, a more extensive range of patients are expected to qualify for TEER procedures. Our comprehensive review sought to extensively explore the background, equipment used, effectiveness of MR and TR, potential side effects, future prospects, and ongoing trials associated with TEER. We further discuss the existing gender, racial, and socioeconomic disparities in the realm of TEER.

Significant tricuspid regurgitation is associated with adverse outcomes in patients with transthyretin amyloid cardiomyopathy

Objectives

Patients diagnosed with transthyretin amyloid cardiomyopathy (ATTR-CM) often experience poor outcomes due to the development of heart failure (HF). Tricuspid regurgitation (TR) has been found to be correlated with adverse outcomes in patients with HF. This study aims to assess whether the presence of significant TR is associated to adverse cardiac outcomes in patients diagnosed with ATTR-CM.

Materials and methods

Retrospective study of ATTR-CM patients enrolled in the Institutional Registry of Amyloidosis (NCT01347047). Patients were categorized based on the presence of significant TR (moderate or severe according to current guidelines criteria) or absence of significant TR. All patients were followed up for 2 years to assess the incidence of the composite outcome of death or HF hospitalization.

Results

A total of 93 ATTR-CM patients were included. The mean age at diagnosis was 82.5 [IQR 75 - 86] years, 86% were male, and the mean left ventricular ejection fraction was 52% [IQR 43 - 60]. Among them, 32.3% (n = 30) patients had significant TR. Patients with significant TR had higher NTpro-BNP values (5308 vs 2454, pg/mL, p = 0.004), and a lower left ventricular ejection fraction (44 vs. 56%, p = 0.0002) compared to patients without significant TR. The incidence of the primary outcome was higher in patients with significant TR (77% vs. 30%, p<0.001). In a multivariate Cox regression analysis, only NTpro-BNP, as a numerical variable (HR 1.00, 95% CI 1.00005-1.0002, p = 0.001), and significant TR (HR 2.23, 95% CI 1.12-4.42, p=0.021) were independently associated with the composite outcome of death or HF hospitalization.

Conclusions

In patients diagnosed with ATTR-CM, the presence of significant TR was associated with worse outcomes.

The Role of Palliative Care in Cardiovascular Disease

The American Heart Association has recommended that palliative care be integrated into the care of all patients with advanced cardiac illnesses. Notwithstanding, the number of patients receiving specialist palliative intervention worldwide remains extremely small. This review examines the nature of palliative care and what is known about its delivery to patients with cardiac illness. Most of the published literature on the subject concern advanced heart failure; however, some data also exist regarding patients with heart transplantation, pulmonary hypertension, valvular disease, congenital heart disease, indwelling devices, mechanical circulatory support, and advanced coronary disease. In addition, outcome data, certification requirements, workforce challenges, barriers to implementation, and a potential caveat about palliative care will also be examined. Further work is required regarding appropriate means of implementation, quality control, and timing of intervention.

Tricuspid Regurgitation in Congestive "End-Organ" Failure: Outline of an Opportunity

Tricuspid regurgitation (TR) is a progressive disease that can be addressed only partially by medical therapy. Progression of TR is associated with worsening end-organ function and worse survival, yet tricuspid valve interventions are usually only performed in advanced stages. Recent evidence suggests a pivotal role for TR and pulsatile venous congestion in the pathophysiology of renal and hepatic dysfunction. This critical knowledge has provided the opportunity to optimally define the appropriate timing of transcatheter tricuspid valve interventions, integrating concurrent or impending functional consequences with severity of TR.

The Current Landscape of Transcatheter Tricuspid Valve Intervention

Tricuspid regurgitation (TR) is common, and its prevalence increases with age. It was previously estimated that there are 1.6 million patients in the United States with moderate or worse TR, and more contemporary data suggest the age-adjusted prevalence of TR is 0.55%. Increasing TR severity is associated with an adverse prognosis independent of the pulmonary artery pressure and the degree of right heart failure. In heart failure with reduced ejection fraction, survival is significantly worsened when moderate or severe TR is present. The mainstay of therapy has traditionally been surgery, but outcomes are poor. There has been increasing attention on the potential role of transcatheter interventions for TR. Numerous platforms are in developmental evolution, which broadly fall into 3 categories: valve replacement, valve repair (subdivided into annular, leaflet, and chordal platforms), and caval valve implantation. In this review, we examine all these strategies and devices, including guidance on how to appropriately select patients who can benefit from intervention.

Key Echocardiographic Considerations for Tricuspid Valve Transcatheter Edge-to-Edge Repair

Chronic tricuspid regurgitation (TR) results in progressive right ventricular (RV) volume overload, followed by right-sided chamber dilatation, RV systolic dysfunction, and eventual low-output cardiac failure. Severe TR is associated with considerable morbidity and mortality, and yet until recently, patients in the late stage of their disease course had limited treatment options. Cognizant of the high mortality rates associated with surgical intervention, tricuspid valve (TV) transcatheter edge-to-edge repair (TEER) has emerged as a promising solution for patients with severe TR. As has been learned from the transcatheter mitral valve TEER experience, detailed morphological and mechanistic assessment of the TV with transthoracic and transesophageal imaging is essential to optimal patient selection and procedural success. The current review will provide a comprehensive overview of TV anatomy, the updated mechanistic classification of TR, and key echocardiographic considerations in the evaluation, management, and follow-up of patients undergoing TV TEER.

Concomitant Transcatheter Edge-to-Edge Treatment of Secondary Tricuspid and Mitral Regurgitation: An Expert Opinion

Secondary (functional) tricuspid regurgitation (sTR) is common in patients with mitral regurgitation (MR). Because combined valvular heart disease affects long-term survival, in comparison with isolated MR or tricuspid regurgitation, it is essential to offer patients adequate treatment. Despite considerable experience, no conclusive data are yet available on the prognostic impact of concomitant tricuspid valve surgery at the time of mitral valve surgery. Emerging transcatheter treatments offer the opportunity to treat both conditions (MR and sTR) simultaneously or in a stepwise fashion. This review provides a clinical overview on available data regarding the rationale for treatment of sTR in patients with relevant MR undergoing mitral transcatheter edge-to-edge repair, focusing on clinical and anatomical selection criteria.

Indications, Limitations, and Development of Tricuspid Valve Interventions in Adults

Tricuspid regurgitation is associated with excessive mortality and poor outcomes regardless of the cause and associated comorbidities. Despite this clear association with mortality, tricuspid valve diseases remain undertreated. Tricuspid valve surgery, either repair or replacement, has shown little detectable survival benefit. Transcatheter tricuspid valve interventions have emerged as a less invasive approach to tricuspid valve diseases. They can be categorised into coaptation devices, annuloplasty devices, transcatheter tricuspid valve replacement, heterotopic caval valve implantation, and tricuspid valve-in-valve. Despite the late referral and the patient's profile, results remain fairly acceptable at least in the short term, with good procedural device success, excellent safety profile, and sustained reduction of tricuspid regurgitation for up to 1 year. Because results are limited to the mid-term, transcatheter tricuspid valve intervention durability will need to be established before broader adoption of these technologies.

Postoperative Pulmonary Complications in Patients With Transcatheter Tricuspid Valve Implantation—Implications for Physiotherapists

Objectives

To investigate the incidence of postoperative pulmonary complications (PPCs) and short-term recovery after transcatheter tricuspid valve implantation (TTVI).

Methods

A total of 17 patients diagnosed with severe tricuspid regurgitation who received a LuX-valve TTVI were included in this study. Spirometry lung function, maximal inspiratory pressure (MIP), and 6-min walk test distance (6MWD) were recorded. Prior to surgery, patients were stratified into high or low pulmonary risk groups based on published predefined criteria. A physiotherapist provided all patients with education on thoracic expansion exercises, effective cough and an inspiratory muscle training protocol at 50% of MIP for 3 days preoperatively. All patients received standard post-operative physiotherapy intervention including positioning, thoracic expansion exercises, secretion removal techniques and mobilization. Patients were assessed for PPCs as defined by the Melbourne-Group Score-version 2. Clinical characteristics and hospital stay, cost, functional capacity, and Kansas City Cardiomyopathy Questionnaire (KCCQ) heart failure score were recorded at admission, 1-week, and 30-days post-op.

Results

The mean (SD) age of the 17 patients was 68.4 (8.0) years and 15 (88%) were female. Pre-surgical assessment identified 8 patients (47%) at high risk of PPCs. A total of 9 patients (53%) developed PPCs between the 1st and 3rd day post-surgery, and 7 of these 9 patients were amongst the 8 predicted as “high risk” prior to surgery. One patient died before the 30 day follow up. Pre-operative pulmonary risk assessment score, diabetes mellitus, a low baseline MIP and 6MWD were associated with a high incidence of PPCs. Compared to those without PPCs, patients with PPCs had longer ICU and hospital stay, and higher hospitalization cost. At 30 days post-surgery, patients without PPCs maintained higher MIP and 6MWD compared to those with PPCs, but there were no significant between-group differences in other lung function parameters nor KCCQ.

Conclusion

This is the first study to report the incidence of PPCs post TTVI. Despite a 3-day prehabilitation protocol and standard post-operative physiotherapy, PPCs were common among patients after TTVI and significantly impacted on hospital and short-term recovery and outcomes. In the majority of patients, PPCs could be accurately predicted before surgery. A comprehensive prehabilitation program should be considered for patients prior to TTVI.

Clinical Trial Registration

[www.ClinicalTrials.gov], identifier [ChiCTR2000039671].

Transcatheter edge-to-edge repair of tricuspid regurgitation in the Netherlands: state of the art and future perspectives

Despite the high prevalence and adverse clinical outcomes of severe tricuspid regurgitation (TR), conventional treatment options, surgical or pharmacological, are limited. Surgery is associated with a high peri-operative risk and medical treatment has not clearly resulted in clinical improvements. Therefore, there is a high unmet need to reduce morbidity and mortality in patients with severe TR. During recent years, several transcatheter solutions have been studied. This review focuses on the transcatheter edge-to-edge repair of TR (TTVR) with respect to patient selection, the procedure, pre- and peri-procedural echocardiographic assessments and clinical outcomes. Furthermore, we highlight the current status of TTVR in the Netherlands and provide data from our initial experience at the University Medical Centre Groningen.

Transcatheter Tricuspid Valve Intervention: Current Perspective

Tricuspid regurgitation (TR) adversely impacts both quality of life and long-term survival, which generates interest in therapeutic approaches to mitigate these effects. Historically, therapeutic options for TR were limited to surgical approaches, which are often complicated by significant morbidity and mortality in elderly patients with multiple comorbidities. This gap in therapeutic options led to the rapid evolution of transcatheter tricuspid valve intervention (TTVI), with a wide variety of approaches pursued and early results suggesting that TTVI improves clinical outcomes. Numerous strategies, including edge-to-edge repair, annular reduction, spacers, caval valve implantation, and transcatheter tricuspid valve replacement form the basis of TTVI today. In this review, the authors discuss the current state of each approach.

Comparison of transcatheter tricuspid valve repair using the MitraClip NTR and XTR systems

BACKGROUND

Transcatheter tricuspid leaflet repair (TTVr) using the MitraClip is a promising option for patients with severe tricuspid regurgitation (TR) and heart failure. However, no comparative studies of the NTR and XTR systems have been reported.

OBJECTIVES

The aim of this study was to assess the relative efficacy, safety, and clinical outcomes of patients with severe TR treated with the MitraClip NTR and XTR systems.

METHODS

Forty consecutive patients with severe TR underwent TTVr. The primary outcome was procedural success, with NYHA functional class, TR grade and major adverse cardiac and cerebrovascular events (MACCE) assessed at 30-day follow-up.

RESULTS

The majority of patients had functional TR and a greater proportion of XTR patients had torrential TR with larger coaptation gaps. Procedural success was achieved in 70% vs 80% in the NTR and XTR cohorts. Single leaflet device attachment was equal in both groups (5%). At 30-day follow-up, 70% vs 85% of NTR and XTR patients were in NYHA Class I/II. The mean reduction in TR grade was greater in the XTR group (1.5 ± 0.3 vs 2.3 ± 0.4, p-0.012). In patients with torrential TR at baseline, 55% in the XTR group achieved TR ≤ 2+ compared to none in the NTR group (p < 0.001).

CONCLUSIONS

In this first study comparing the MitraClip NTR and XTR systems for TTVr, we found both to be safe and effective, while the XTR system allowed treatment of larger coaptation gaps, greater mean reduction in TR grade, with more effective reduction of torrential TR.

Visualisation of the tricuspid valve using a new 3D echocardiographic scoring system

With rising focus on interventional treatment of the tricuspid valve (TV), the need for good echocardiographic imaging increases. Aim of this study was to develop a scoring system describing how accurate three dimensional (3D) echocardiographic imaging of TV and its anatomical structures is.

Transcatheter Tricuspid Valve Intervention: Coaptation Devices

Transcatheter tricuspid valve intervention (TTVI) has recently emerged as an alternative for the treatment of severe tricuspid regurgitation (TR). Multiple percutaneous devices have been developed in the last decade with promising early results. Among them, the coaptation devices are designed to reduce TR severity by valve leaflet plication or occupying the regurgitant orifice with a spacer. To date, the MitraClip/TriClip devices (Abbott, Santa Clara, CA, USA), the PASCAL system (Edwards Lifesciencies, Irvine, CA, USA), and the FORMA device (Edwards Lifesciencies, Irvine, CA, USA) have been used as coaptation devices for treating severe TR. The present document aimed to review the clinical evidence on coaptation devices in the field of TTVI, describing its design characteristics, main procedural steps, and early and mid-term outcomes.

Value of Echocardiographic Right Ventricular and Pulmonary Pressure Assessment in Predicting Transcatheter Tricuspid Repair Outcome

OBJECTIVES

The aim of this study was to assess the value of echocardiographic right ventricular (RV) and systolic pulmonary artery pressure (sPAP) assessment in predicting transcatheter tricuspid edge-to-edge valve repair (TTVR) outcome.

BACKGROUND

RV dysfunction and pulmonary hypertension are associated with poor prognosis and are systematically sought during tricuspid regurgitation evaluation. The value of echocardiographic assessment in predicting TTVR outcome is unknown.

METHODS

Data were taken from the TriValve (Transcatheter Tricuspid Valve Therapies) registry, which includes patients undergoing TTVR at 14 European and North American centers. The primary outcome was 1-year survival free from hospitalization for heart failure, and secondary outcomes were 1-year survival and absence of hospital admission for heart failure at 1 year.

RESULTS

Overall, 249 patients underwent TTVR between June 2015 and 2018 (mean tricuspid annular plane systolic excursion [TAPSE] 15.8 ± 15.3 mm, mean sPAP 43.6 ± 16.0 mm Hg). Tricuspid regurgitation grade ≥3+ was found in 96.8% of patients at baseline and 29.4% at final follow-up; 95.6% were in New York Heart Association functional class III or IV initially, compared with 34.3% at follow-up (p < 0.05). Final New York Heart Association functional class did not differ among TAPSE and sPAP quartiles, even when both low TAPSE and high sPAP were present. Rates of 1-year survival and survival free from hospitalization for heart failure were 83.9% and 78.7%, respectively, without significant differences according to baseline echocardiographic RV characteristics (TAPSE, fractional area change, and end-diastolic area) and sPAP (p > 0.05 for all).

CONCLUSIONS

TTVR provides clinical improvement, with 1-year survival free from hospital readmission >75% in patients with severe tricuspid regurgitation. Conventional echocardiographic parameters used to assess RV function and sPAP did not predict clinical outcome after TTVR.

Treatment of Severe TRIcuspid Regurgitation in Patients with Advanced Heart Failure with CAval Vein Implantation of the Edwards Sapien XT VALve (TRICAVAL): a randomised controlled trial

AIMS

The aim of our study was to compare the impact of implantation of a balloon-expandable transcatheter valve into the inferior vena cava (CAVI) on exercise capacity with optimal medical therapy (OMT) in patients with severe tricuspid regurgitation (TR) and high surgical risk.

METHODS AND RESULTS

Twenty-eight patients were randomised to OMT (n=14) or CAVI (n=14). The primary endpoint was maximal oxygen uptake at the three-month follow-up. Secondary endpoints included six-minute walk test, NYHA class, NT-proBNP levels, right heart function, unscheduled heart failure hospitalisation, and quality of life as assessed by the Minnesota Living with Heart Failure Questionnaire (MLHFQ). Patients underwent follow-up examinations one, three, six, and twelve months after randomisation. Maximal oxygen uptake did not change significantly in either group after three months and there was no difference between the OMT and CAVI groups (-0.1±1.8 ml∙kg-1∙min-1 vs -1.0±1.6 ml∙kg-1∙min-1, p=0.4995). Compared to baseline, CAVI improved NYHA class, dyspnoea, and quality of life after three months. However, there were no statistically significant differences in the secondary endpoints between the groups. Four periprocedural complications occurred after CAVI, resulting in open heart surgery. Four patients in the OMT group and eight patients (including four after conversion to surgery) in the CAVI group died from right heart failure, sepsis or haemorrhage.

CONCLUSIONS

CAVI did not result in a superior functional outcome compared to OMT. Due to an unexpectedly high rate of valve dislocations, the study was stopped for safety reasons.

Clinical impact of elevated tricuspid valve inflow gradients after transcatheter edge-to-edge tricuspid valve repair

AIMS

The aim of this study was to compare the outcome of patients with a post-procedural tricuspid valve gradient (TVG) of >3 mmHg vs ≤3 mmHg after transcatheter edge-to-edge tricuspid valve repair (TTVR).

METHODS AND RESULTS

Between March 2016 and October 2018 we treated 145 patients with severe tricuspid regurgitation (TR) with TTVR by placing 2.2±0.7 clips per patient. Device success (TR reduction ≥1° to at least moderate) was achieved in 125 patients (86.2%). TTVR resulted in an elevated TVG >3 mmHg in 25 (17.2%) patients. Device success (84% vs 86.7%, p=0.9), number of clips implanted (2.3±0.7 vs 2.2±0.7, p=0.33), clinical improvement including NYHA class (III/IV 24% vs 28%, p=0.92) and increase in six-minute walking test at one month (67 m [IQR 5-103 m] vs 56 m [IQR 8-97 m], p=0.93), mortality (HR 1.07, 95% CI: 0.43-2.65, plogrank=0.88) and the combined endpoint mortality and hospitalisation for heart failure at one year (HR 1.07, 95% CI: 0.46-2.48, plogrank=0.88) were similar between patients with a TVG >3 mmHg versus patients with a TVG ≤3 mmHg.

CONCLUSIONS

A small cohort of patients demonstrated an elevated TVG higher than 3 mmHg at discharge. This elevation had no impact on clinical improvement, mortality or hospitalisation for heart failure.

1-Year Outcomes After Edge-to-Edge Valve Repair for Symptomatic Tricuspid Regurgitation: Results From the TriValve Registry

OBJECTIVES

The purpose of this study was to evaluate procedural and 1-year clinical and echocardiographic outcomes of patients treated with tricuspid edge-to-edge repair.

BACKGROUND

Transcatheter edge-to-edge repair has been successfully performed in selected patients with symptomatic tricuspid regurgitation (TR) and high risk for surgery, but outcome data are sparse.

METHODS

This analysis of the multicenter international TriValve (Transcatheter Tricuspid Valve Therapies) registry included 249 patients with severe TR treated with edge-to-edge repair in compassionate and/or off-label use. Clinical and echocardiographic outcomes were prospectively collected and retrospectively analyzed.

RESULTS

In 249 patients (mean age 77 ± 9 years; European System for Cardiac Operative Risk Evaluation II score 6.4% [interquartile range: 3.9% to 13.9%]), a successful procedure with TR reduction to grade ≤2+ was achieved in 77% by placement of 2 ± 1 tricuspid clips. Concomitant treatment of severe TR and mitral regurgitation was performed in 52% of patients. At 1-year follow-up, significant and durable improvements in TR severity (TR ≤2+ in 72% of patients) and New York Heart Association functional class (≤II in 69% of patients) were observed. All-cause mortality was 20%, and the combined rate of mortality and unplanned hospitalization for heart failure was 35%. Predictors of procedural failure included effective regurgitant orifice area, tricuspid coaptation gap, tricuspid tenting area, and absence of central or anteroseptal TR jet location. Predictors of 1-year mortality were procedural failure, worsening kidney function, and absence of sinus rhythm.

CONCLUSIONS

Transcatheter tricuspid edge-to-edge repair can achieve TR reduction at 1 year, resulting in significant clinical improvement. Predictors of procedural failure and 1-year mortality identified here may help select patients who will benefit most from this therapy.

Transcatheter Edge-to-edge Repair of Severe Tricuspid Regurgitation

Despite the increasing knowledge of the long-term adverse consequence of severe tricuspid regurgitation (TR), most patients with moderate- to-severe TR are still treated conservatively because of the high risk of surgery. Percutaneous procedures have emerged as an attractive alternative treatment. Transcatheter edge-to-edge repair is a validated technique to treat mitral regurgitation. In recent years, the same concept has been applied to patients with TR and prohibitive operative risk. Early trials have shown feasibility and safety. More clinical experiences and long-term results are still being gathered. In this article, we provide an overview of transcatheter edge-to-edge repair and look at the current evidence and clinical results regarding procedure.

Emerging Transcatheter Options for Tricuspid Regurgitation

Tricuspid regurgitation (TR) presents as either primary valve pathology or secondary to pulmonary or left-sided heart disease. Severe TR portends a worse prognosis independent of age, right ventricular size and function, severe left ventricular dysfunction, and increased pulmonary arterial pressures. Surgical treatment for TR has mostly been limited to patients undergoing mitral valve repair since those at high surgical risk are not candidates for traditional TR surgery. For these patients, minimally invasive techniques could be of great benefit, yet these techniques have been slow to develop because of the various anatomic and physiological aspects of the tricuspid valve apparatus. Several promising new techniques are currently undergoing clinical investigation, including caval valve implantation, percutaneous tricuspid annuloplasty techniques (Trialign, TriCinch, Cardioband), edge-to-edge repair with the MitraClip system, the FORMA device, and the GATE tricuspid Atrioventricular Valved Stent. Further evaluation of their safety and long-term efficacy is warranted prior to commercial approval and widespread adoption.

Six-month outcome after transcatheter edge-to-edge repair of severe tricuspid regurgitation in patients with heart failure

AIMS

Severe tricuspid regurgitation (TR) is common in patients with right-sided heart failure (HF) and causes substantial morbidity and mortality. Treatment options beyond medical therapy are limited for high-risk patients. Transcatheter edge-to-edge tricuspid valve (TV) repair showed procedural safety and short-term efficacy. Impact on mid-term outcome is unclear. This dual-centre observational study evaluates the mid-term safety, efficacy and clinical outcome after edge-to-edge TV repair for severe TR in patients with HF.

METHODS AND RESULTS

Overall, 50 patients with right-sided HF and severe TR were treated with the transcatheter edge-to-edge repair technique; 14 patients were treated for isolated TR and 36 patients for combined mitral regurgitation (MR) and TR. At 6-month follow-up (available for 98% of patients), a persistent reduction of at least one echocardiographic TR grade was achieved in 90% of patients and New York Heart Association class improved in 79% of patients. The 6-minute walk distance increased by 44% (+84 m, P < 0.001), the median N-terminal pro-B-type natriuretic peptide decreased by 30% (from 3625 to 2526 pg/mL, P = 0.002), and the quality of life score improved by 16% (decrease of 6 points in the Minnesota Living with Heart Failure Questionnaire score, P = 0.056). The improvements were comparable in patients undergoing isolated TR or combined MR and TR treatment. During follow-up, 8 patients died, 14 were hospitalized for worsening of HF, 2 underwent TV surgery, and 2 received a second TV clip procedure.

CONCLUSIONS

Transcatheter edge-to-edge TV repair for severe TR is safe and effective in reducing TR. It appears to be associated with improved clinical outcome in the majority of patients.

Transcatheter valve interventions in heart failure: new answers to old questions

Heart failure (HF) is often associated with different valve diseases, predominantly functional mitral and tricuspid regurgitation. However, the association between HF and aortic stenosis, particularly low-flow low-gradient aortic stenosis, is not infrequent. Severe mitral and tricuspid regurgitations, as well as aortic stenosis, in HF patients worsen prognosis and left ventricular dilatation and induce further reduction in left ventricular ejection fraction. Transcatheter edge-to-edge mitral and tricuspid valve repair and transcatheter aortic valve implantation could be an important therapeutic option with a satisfactory long-term outcome in HF patients with comorbidities and even in patients with severely depressed ejection fraction.

Recent advances in managing tricuspid regurgitation

Isolated tricuspid valve surgery is usually carried out with very high morbidity and mortality given the complexity of the affected patients. In light of this, trans-catheter tricuspid valve interventions have been emerging as an attractive alternative to surgery over the last few years. Although feasibility has been shown with a number of devices, clinical experience remains preliminary and associated with significant clinical and technical challenges. Here we describe currently available trans-catheter treatment options for severe tricuspid regurgitation implanted in different locations.

Transcatheter therapies for tricuspid regurgitation: coaptation augmentation devices

Advancements in transcatheter technology has increased the number of therapeutic options for patients with tricuspid regurgitation. One category of repair devices attempts to augment leaflet coaptation by either leaflet plication or by functioning as a space occupying device. These include the MitraClip (Abbott, Santa Clara, CA, USA), PASCAL (Edwards Lifesciences, Irvine, CA, USA) and FORMA (Edwards Lifesciences, Irvine, CA, USA) devices. All three have been successfully implanted with promising short-term echocardiographic and clinical outcomes. Improvements in patient selection, device design and procedural technique will lead to more effective tricuspid regurgitation reduction. Further research to assess efficacy, safety and durability of these devices is needed, along with determination of long-term clinical outcomes.

Contemporary Trends in the Use and Outcomes of Surgical Treatment of Tricuspid Regurgitation

Background

Tricuspid regurgitation (TR), if untreated, is associated with an adverse impact on long‐term outcomes. In recent years, there has been an increasing enthusiasm about surgical and transcatheter treatment of patients with severe TR. We aim to evaluate the contemporary trends in the use and outcomes of tricuspid valve (TV) surgery for TR using the National Inpatient Sample.

Methods and Results

Between January 1, 2003 and December 31, 2014, an estimated 45 477 patients underwent TV surgery for TR in the United States, of whom 15% had isolated TV surgery and 85% had TV surgery concomitant with other cardiac surgery. There was a temporal upward trend to treat sicker patients during the study period. Patients who underwent isolated TV repair or replacement had a distinctly different clinical risk profile than those patients who underwent TV surgery simultaneous with other surgery. Isolated TV replacement was associated with high in‐hospital mortality (10.9%) and high rates of permanent pacemaker implantation (34.1%) and acute kidney injury requiring dialysis (5.5%). Similarly, isolated TV repair was also associated with high in‐hospital mortality (8.1%) and significant rates of permanent pacemaker implantation (10.9%) and new dialysis (4.4%). Isolated TV repair and TV replacement were both associated with protracted hospitalizations and substantial cost.

Conclusions

In contemporary practice, surgical treatment of TR remains underused and is associated with high operative morbidity and mortality, prolonged hospitalizations, and considerable cost.

Tricuspid Clip: Step-by-Step and Clinical Data

Symptomatic severe tricuspid regurgitation (TR), if untreated, carries a dismal prognosis. These patients are at very high risk for surgical repair or replacement and transcatheter options to treat TR are emerging. More than 300 transcatheter tricuspid repairs with the MitraClip system have been performed worldwide with promising results. The TriClip system, with the MitraClip NT delivered via a dedicated tricuspid steerable guide catheter, is currently under investigation. This article describes the step-by-step technique on using the MitraClip system to perform transcatheter tricuspid repair using echocardiographic and fluoroscopic guidance. The latest data on worldwide experience with tricuspid clipping are also discussed.