Current Status of Tricuspid Valve Interventions in Asia Pacific Region

Abstract

Transcatheter tricuspid interventions are becoming increasingly more common in Asia Pacific. In the past decade, clinicians in Asia Pacific have worked with a multitude of new transcatheter tricuspid technologies. A standardized clinical algorithm to diagnose symptomatic tricuspid regurgitation to increase patient access to novel right heart therapies has not yet been identified. Anatomic diversity in the Asia Pacific patient population; disease prevalence patterns; and socioeconomic, cultural, and local health structures represent unique challenges in the treatment of these patients with right heart failure. As advancements are made in right heart failure and transcatheter tricuspid technologies, hopefully more patients can be treated not just in Asia Pacific, but across the entire world.

Keywords: Asia Pacific; transcatheter annuloplasty; transcatheter edge-to-edge repair; transcatheter tricuspid valve replacement; tricuspid regurgitation.

Graphical abstract

Central Illustration

Features of Tricuspid Regurgitation in Asia Pacific Region Although the prevalence of tricuspid regurgitation (TR) across the Asia Pacific region (APAC) nations is similar to the prevalence reported in European and North (N) American registries, there is a greater prevalence of degenerative and rheumatic TR among the APAC nations. The diversity of health care infrastructure and socioeconomic challenges amongst the different APAC countries affect patient access to new technologies and treatment options.

Figure 1

Algorithm for Evaluating Symptomatic Tricuspid Regurgitation Patients Proposed multidisciplinary heart team considerations when approaching clinical evaluation of a patient with severe symptomatic tricuspid regurgitation incorporate multimodality imaging physician expertise, surgical candidacy considerations, goal-directed medical therapy optimization, and anatomical evaluation for potential transcatheter tricuspid interventions. CMR = cardiac magnetic resonance imaging; CT = computed tomography; GDMT = guideline-directed medical therapy; L = left; R = right; RHC = right heart catheterization; TEE = transesophageal echocardiogram; TEER = transcatheter edge-to-edge repair; TTE = transthoracic echocardiogram; TTVR = transcatheter tricuspid valve replacement.

Figure 2

Imaging Evaluation Algorithm for Transcatheter Tricuspid Valve Interventions Multi-pronged multimodality imaging analysis is required for transcatheter tricuspid interventions. Multimodality imaging assists in anticipating and optimizing case-procedural planning to help the implanting team anticipate and overcome potential anatomical challenges. CT = computed tomography; RA = right atrium; RCA = right coronary artery; RV = right ventricle; TR = tricuspid regurgitation; other abbreviations as in Figure 1.

Figure 3

Computed Tomography 3-Dimensional Reconstruction Showing Atrial vs Ventricular Secondary Tricuspid Regurgitation (A) Atrial secondary tricuspid regurgitation; (B) ventricular secondary tricuspid regurgitation. (C) Overlapping features of atrial and ventricular secondary tricuspid regurgitation with basal enlargement of the right ventricle with right atrial enlargement. IVC = inferior vena cava; SVC superior vena cava.

Figure 4

Overview of Current Transcatheter Tricuspid Valve Devices in Asia Pacific Current TEER, TTVR, caval valve, and annuloplasty technologies currently available in commercial or investigational trial within Asia Pacific region are depicted. Abbreviations as in Figure 1.

Figure 5

Intraprocedural Images of a Tricuspid-Transcatheter-Edge-to-Edge Repair Using the TriClip Device (A) Fluoroscopy of a TriClip Steerable Guide Catheter (SGC) and Clip Deliver (CDS) System. (B) Transesophageal echocardiogram (TEE) 3-dimensional (3D) multiplanar reconstruction (MPR) to guide the steering of TriClip system. (C) TEE transgastric view to confirm the clip arm orientation and tissue bridge after clip closure. (D) TEE midesophageal view to assess final tricuspid regurgitation after clip implantation.

Figure 6

Multimodality Imaging to Guide K-Clip Transcatheter Annuloplasty (A) Preoperative computed tomography was performed to assess the tricuspid annulus (TA) dimension and the proximity of right coronary artery (RCA) to the TA. (B) Fluoroscopic projection for device implantation was determined. (C) During the procedure, an RCA guide catheter (GC) with a coronary wire is inserted to look for any coronary impingement by the K-Clip, and 3D TEE MPR is used to guide the steering and implantation of K-Clip. Abbreviations as in Figure 5.

Figure 7

Multimodality Imaging to guide the LuX Transcatheter Tricuspid Valve Replacement (A) Preoperative computed tomography (CT) was performed to assess the tricuspid annulus size, right atrial (RA) and right ventricular (RV) length, interventricular septum angulation, and device fluoroscopic implantation projection. (B) TEE 3D MPR is used to guide the steering of delivery system. (C) Fluoroscopy and TEE STR used to assess the location of the 2 graspers (white arrows) of the LuX valve. (D) TEE at midesophageal view confirms contact of the septal anchor with the interventricular septum. (E) After septal anchor implantation, the LuX valve is deployed. (F) Follow-up imaging shows the supra-annular cuff of the LuX valve apposed to the right atrial wall to minimize any paravalvular leak, and the position of the septal anchor within the interventricular septum. Abbreviations as in Figure 5.

Figure 8

Multimodality Imaging to Guide TricValve Heterotopic Transcatheter Tricuspid Valve Replacement (A) Preoperative CT was performed to assess the sizes of SVC, IVC, and the distance of right atrium to the first hepatic vessel. (B) Implantation of the SVC valve with the belly (white arrow) of the valve positioned superior to the pulmonary artery additionally confirmed by a pulmonary artery (PA) catheter. (C) TTE showing the IVC valve in-situ with the presence of severe tricuspid regurgitation (TR). (D) The implanted IVC valve blocks contrast flow from right atrium (RA) to IVC and causes significant pressure gradient between RA and IVC. Abbreviaitons as in Figures 1 and 3.

Figure 9

3D ICE to Guide Tricuspid TEER (A) 3-dimensional (3D) intracardiac echocardiography (ICE) (Siemens) showing the tricuspid valve (TV) anatomy. (B) 3D ICE is used to guide clip steering and clip arm orientation. (C) 3D ICE (Philips) multiplanar reconstruction (MPR) to assess leaflet insertion during Tricuspid-TEER. (D) 3D ICE biplane imaging demonstrating clip insertion on both the anterior (A) and septal (S) leaflets. P = posterior.

Figure 10

Future Challenges in Treatment of Symptomatic TR Future challenges in the treatment of tricuspid regurgitation (TR) include evaluating the role of atrial fibrillation rhythm control; the role of medical therapy; the relationship of TR with heart failure with preserved ejection fraction (HFpEF); the optimal pacing strategy to minimize TR; and the value, optimal timing, and optimal strategy of TR interventions.