Catheter-based treatment of tricuspid regurgitation: state of the art

Abstract

Tricuspid regurgitation is a highly prevalent condition, with detrimental effects on long-term survival. However, it has been historically neglected, and only surgically addressed when symptomatic diuretic agents proved insufficient to alleviate congestion. Besides, mortality rates of isolated tricuspid regurgitation surgery have been persistently high, even in contemporary series. This has led to the advent of a myriad of transcatheter tricuspid valve interventions mimicking current surgical technologies, for which a comprehensive imaging work-up holds the key for proper patient selection and intraprocedural monitoring. Although initially designed for compassionate use patients, growing experience and encouraging results of these less-invasive technologies are broadening the spectrum of beneficiaries. In this review, we will focus on the current picture of transcatheter tricuspid valve interventions, with special interest on the current understanding of pathoanatomic tricuspid regurgitation progression, preprocedural multimodality imaging and the latest experience on the different transcatheter devices.

Keywords: Tricuspid regurgitation (TR); transcatheter therapies.

Figure 1

Annual trends in surgical volume and mortality for isolated tricuspid valve surgery. As the total amount of both isolated tricuspid valve replacement and repair has risen in from 2004 to 2013, in-hospital mortality has held steady in a median 8.8% ratio. Reproduced with permission from (6).

Figure 2

Anatomy of tricuspid valve and surrounding structures. Yellow triangle depicts the triangle of Koch, delineated by the septal leaflet, the tendon of Toaro and the coronary sinus. The star marks the location of the atrioventricular node. Reproduced with permission from (9).

Figure 3

Stepwise heart team decision-making for treatment of tricuspid regurgitation. The implementation of a complete patient risk stratification in addition to a comprehensive imaging work-up for the assessment of cardiac pathological remodeling may aid in the accurate heart team to provide appropriate treatment (surgical, minimal invasive surgical, transcatheter, pharmacological, or palliative). Reproduced with permission from (14).

Figure 4

Transcatheter tricuspid repair devices. There are several techniques to percutaneously repair tricuspid regurgitation, which can be classified according to its anatomic target. In the illustration, examples of coaptation devices [MitraClip (A), PASCAL (B)], suture annuloplasty [TriAlign (C), TriCinc (D)] and ring annuloplasty [Milipede IRIS (E), Cardioband (F)]. Reproduced with permission from (26).

Figure 5

Transcatheter tricusdid replacement devices. Current TTVR prosthesis. (A) Navigate; (B) LUX-Valve; (C) Trisol. Reproduced with permission from (69).

Figure 6

Heterotopic caval valve devices. Current prosthesis for heterotopic caval valve implantation: (A) Edwards Sapien 3; (B) TricValve; (C) Tricento. Reproduced with permission from (74).

Figure 7

Algorithm for transcatheter tricuspid valve repair in different stages. CAVI, caval valve implantation; FTR, functional tricuspid regurgitation; PH, pulmonary hypertension; TA, tricuspid annulus; TTVR, transcatheter tricuspid valve replacement. Adapted with permission from (16).