Catheter-Based Therapy for Tricuspid Valve Disease: Practical Considerations for Interventionalists

Large tricuspid annulus dimensions with a non-planar and elliptical shape

Absence of calcifications

RV morphology (trabeculae, muscle bands, thin apical wall)

Proximity/contiguity of other structures (coronary sinus, atrioventricular node and His bundle, vena cava, right coronary artery)

Angulation of the annulus in relation to the superior vena cava and inferior vena cava

The Importance of Imaging: Patients’ Eligibility and Intraprocedural Guidance

With the advent and availability of transcatheter TV therapies, computed tomography (CT) has become a mandatory in defining patients’ anatomy and eligibility.

Since it offers a comprehensive assessment of the real three-dimensional (3D) anatomy, CT allows the operator to assess the TV anatomy as well as the adjacent structures including the proximity of the right coronary artery to the tricuspid annulus, the coronary sinus, the hepatic veins and vena cava (Fig. 19.1a). For some devices it is crucial also the assessment of the shape and dimension of the RV, including the distant between the RV apex and the annular plane (this is the case for the valve spacer). Moreover, angio-CT allow the operator to have a qualitative assessment of the tissue quality, which is particular important for annulopasty devices which rely on anchor fixation, in order to identifhy the optimal target zone for the implant. Another features of CT scan is that it allows for each patient an easy and reliable prediction of the fluoroscopic working plane during the procedure, which are usually 2, one en-face view (normally LAO) and one view parallel to the annulus (normally RAO).


Fig. 19.1
Imaging of the tricuspid valve. (a) Angio-computed tomography of tricuspid valve and right heart structures characterization for pre-procedural planning. TV tricuspid valve, APC antero posterior commissure, ASC antero septal commissure, RCA right coronary artery, AV aortic valve, RA right atrium, RV right ventricle, SVC superior vena cava, IVC inferior vena cava, RVOT right ventricular outflow tract, Pa pulmonary artery. (b) Identification of TV leaflets and localization of the each commissures with tree dimensional transesophageal echocardiography; SP septoposterior, AS anteroseptal, and AP anteroposterior, commissures

Transesophageal 2D and 3D echocardiography (TEE) is also the essential imaging technique in the assessment of patients with TR (Fig. 19.1b), in order to assess the mechanism and location of regurgitation, to quantify the annular dimensions and to assess the RV function and valve tethering.

Although preliminary experience showed the feasibility of TV interventions, intraprocedural guidance remain a major issue, since in many patients the echocardiographic window for the TV may be suboptimal and the procedural steps have not yet been standardized. Both two-dimensional (2D) and 3D TEE as well as intracardiac echocardiography (ICE) also play an essential role during transcatheter TV interventions. In some patients, transthoracic echocardiography (TTE) may help to define TV morphology and right ventricular anatomy to identify the target zone of the device implantation. This is particular helpful in MitraClip procedures , in which a proper assessment of the leaflets insertion is mandatory to achieve procedural success [8]. Procedural guidance with 3D-TEE represents a fundamental tool to orient the navigation in the right atrium. However, in many patients the quality of intra-procedural guidance can often be suboptimal, mainly depending on patient variability and individual echo window. Moreover, the three-leaflet configuration of the TV precludes the visualization of all the leaflets in the same view in conventional 2D echo. This aspect contributes to increase technical complexity of TV interventions. A detailed intra-procedural imaging is of particular importance not only to guide the operator to the segment of the valve which represent the target leaflet or commisure, but is crucial to define the orientation of the anatomy and to assess leaflet insertion. The use of the EchoNavigator®-system (Philips Healthcare, Best, the Netherlands) may help to overcome the intrinsic limits of imaging guidance in TV interventions, since multimodality fusion imaging may define the target zone increases tremendously the chance of procedural success [7]. Additionally, it is of crucial importance to define a common nomenclature in order to standardize procedural 3D TEE guidance. It should be shared between the one who is performing the procedure and the one who is guiding. With this in mind, a communication between the heart team (e.g. echo-cardiologist, interventionalist and surgeon) is fundamental; therefore, all the operators involved in the procedure should speak “the same language”. This is even more important at this stage, and this can avoid some misunderstand “the eyesight” in each staff. We recently propose a “Rosetta Stone” nomenclature for 3D TEE navigation during transcatheter TV interventions as practical considerations for the heart team [13]. The identification of the location of the aortic valve (AV) is fundamental to understand the orientation of the leaflets: the leaflet opposite to the AV is the posterior leaflet. Anterior and septal leaflets are easily identified counterclockwise (Fig. 19.2).


Fig. 19.2
Navigation in the right atrium with 3D TEE during transcatheter tricuspid intervention (AV aortic valve, A anterior, S Septal, P Posterior, CS, coronary sinus). The three stars indicate the valve commissure; the yellow spot indicate an intravalvulare pacemaker lead; the red arrow indicated the inferior vena cava

Specific Considerations for Transcatheter Tricuspid Valve in Valve and Valve in Ring

In patients with previous tricuspid surgery, transcatheter valve-in-valve or valve-in-ring procedures can be performed using a transfemoral or transjugular approach even in patients with pre-existing transvalvular pacemaker leads [911]. Different prostheses have been used to perform tricuspid valve in valve and valve in ring (mainly Sapien XT, Sapien 3 and Melody).

The transfemoral approach may be technically challenging in most cases, due to an unfavorable narrow angle between the inferior vena cava (IVC) and the TV, which may preclude positioning of the prosthesis valve, especially in case of Sapien XT and Sapien 3 valve, which have a pretty stiff delivery system. By snaring the Commander catheter , flexion of the system can be increased by simple pulling on the snare, thereby adapting the angle of the catheter to the patient’s anatomy (Fig. 19.3) [9].


Fig. 19.3
Transcatheter tricuspid valve replacement. “Snare-guided” (asterisk) crossing technique of the tricuspid valve to optimise the angle and obtain coaxiality with tricuspid valve

Regarding valve in ring, in the tricuspid position surgical rings usually are incomplete ring and have a non-circular and non-planar shape. As a result, compared to mitral position, tricuspid valve-in-ring presents some specific difficulties. On the other hand, unlike the mitral position, the risk of right ventricle (RV) outflow obstruction is absent, and residual paravalvular leak and risk of embolization are less of an issue as a result of the low-pressure RV system. As a support for prosthesis sizing, during the procedure, balloon sizing may be useful to determine the annulus dimension more precisely [12]. Although the ring has the advantage of providing the landmarks and necessary anchoring for a percutaneous valve, it also has the drawback of creating a non-circular landing zone with the inability to seal completely the open segment with the implanted valve. Therapeutic advances with more conformable or repositionable valves with additional sealing capacity are required to reduce regurgitation after transcatheter valve-in-ring implantation.

Specific Considerations for Transcatheter Tricuspid Valve Repair Devices

In patients with native TV disease, many percutaneous techniques mimic surgical techniques is innovated. Novel transcatheter devices have begun to emerge for the treatment of TR, and these transcatheter devices are currently under preliminary clinical evaluation to treat functional TR. Risks and limitations of each devices have to be taken in consideration in the patient selection process (Fig. 19.4).


Fig. 19.4
Transcatheter therapies for severe tricuspid regurgitation. (a) Trialign device, (b) Mellipede device, (c) MitraClip device, (d) Cardioband device, (e) Tricinch device, (f) TRAIPTA device, (g) Caval valve implantation, (h) FORMA device

Tricuspid Clipping

More than 60 cases of MitraClip implants in tricuspid position have been performed worldwide [14], but procedural steps have not been standardized yet. The major challenge of this technique is the imaging guidance, since in most of the patients a proper visualization of the leaflet and therefore of the grasping and proper may be problematic. Usually a combination of TEE and TTE may help to overcome the difficulty in visualization. Another open issue of MitraClip is the access: while the first cases have been performed through a transjugular approach, now the preferred route seems to be the femoral one, considering also that in many cases tricuspid clipping is performed concomitantly to a MitraClip in mitral position. A modified delivery system for tricuspid clipping is under development and multicenter feasibility trial should start in Europe in the next months.

Tricuspid Annuloplasy Devices

A possible drawback of the tricuspid annuloplasty devices (Trialign procedure (Mitralign Inc., Tewksbury, MA), TriCinch system (4Tech Cardio Ltd., Dublin, Ireland), Millipede annular ring (Millipede, Santa Rosa, CA) or Cardioband (Edwards Lifesciences, Irvine, CA)), is that they are mostly technically challenging and require advanced imaging guidance and operators’ skills.

Especially, it is mandatory to pay attention the risk of leaflet or right coronary artery damage due to the positioning of the devices and to the annular plication. In this regard, the use of ICE is particularly useful to guide precise implant in the annular tissue avoiding leaflet tears.

Caval Valve Implantation

Heterotopic TV implantation is an alternative approach to an orthotopic implantation. There are still some unsolved issues concerning the tolerability of this palliative technique, especially regarding the risk of deterioration of RV function by increasing preload in patients with prior depressed RV function. These procedures were performed in patients with sufficiently preserved RV function.

Pericardial Device

In common with all permanent implants, potential failure modes are implant migration and tissue erosion. The main limitation of pericardial approach that could importantly limit the clinical adoption of the TRAIPTA system (Cardiovascular Intervention Program at National heart, lung, and blood institute) is that in a large majority of the cases functional TR is observed in patients with previous open-heart operation, in whom the pericardium was opened. Therefore, navigation in the pericardial space is challenging if not impossible due to the surgical adhesions.

Tricuspid Valve Spacer

The FORMA Repair System (Edwards Lifesciences, Irvine, CA) is achieved under general anesthesia under fluoroscopic and 2D or 3D TEE guidance. However, the presence of the spacer between the valve leaflets makes the accurate assessment of the degree of TR after the procedure difficult.

How to Report the Outcome?

Another practical consideration that has to be done refers to how to report the outcomes of these new tricuspid therapies, since no standardized definitions are present. First of all, it would be recommendable to report precise quantitative measurements of TR reduction (like EROA and Regurgitant Volume). Secondarily, it is not really clear which will be the best outcome to evaluate in these patients, since most likely improvement in quality of life would be more appropriate than improvement in survival. Anyway, similarly to what has been done for aortic and mitral valves, there is an urgent need for a consensus regarding standardized end-point and reporting outcomes in transcatheter tricuspid interventions.

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Dec 30, 2017 | Posted by in CARDIOLOGY | Comments Off on Catheter-Based Therapy for Tricuspid Valve Disease: Practical Considerations for Interventionalists

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