5.3 Tricuspid Valve Interventions: Repair or Replace?

These proceedings summarize the educational activity of the 16th Biennial Meeting of the International Andreas Gruentzig Society held January 31-February 3, 2022 in Punta Cana, Dominican Republic

Faculty Disclosures     Vendor Acknowledgments

2022 IAGS Summary Document

Statement of the problem or issue

The tricuspid valve (TV) is a monster valve, and by this I mean in terms of what happens when people have longstanding annular dilatation, causing the right atrium and the annulus both to enlarge dramatically. When this happens, leaflet edge technologies are likely going to play only a minor role. There are 3 leaflets to the TV: the anterior leaflet, the septal leaflet, and the posterior leaflet. One thing that is very common and underappreciated is a pacemaker-induced TV dysfunction. All of us dealing with TR know what I mean, and unfortunately electrophysiologists almost never see the problem: the device lead fixes or plasters the septal leaflet down against the wall, or in some cases there are actually redundant leads across the TV, causing massive tricuspid regurgitation (TR). In the pacemaker clinic the device thresholds are okay, and that’s fine, but nobody notices the patient’s legs are swelling up. A lot of this likely will resolve with the advent of leadless pacemakers, but unfortunately, TR is very difficult to treat because the patients really don’t become symptomatic for months to a year. So, months later they go back to their primary care doctor with swollen legs, and their primary doctor will give them diuretics, etc., and never send any feedback to the electrophysiologist that the lead is causing massive TR. By the time it’s recognized the lead have already fixed or plastered the leaflet down. Another common situation we deal with as the population ages will be atrial fibrillation, so MR/TR. Those patients are going to have wide open TR and the biggest problem with TR is that it is a mortality issue.¹

In addition, in the structural heart disease environment there’s a problem with our TAVR patients. We have learned that TR in these patients impacts their survival, perhaps even more so than the aortic valve problem.²

Gaps in knowledge

Almost everything we confront in the TV space is a knowledge gap: historically it has been the “forgotten valve.”

Possible solutions and future directions

Replacement of the TV rather than repair is likely where we are headed over the next 10 years. For example, Edwards has produced the Evoque valve, which has recently reported favorable clinical results.^3,4 This device is shown in Figure 1.

In addition, there are other new technologies under investigation; some of them are focused on leaflet repair rather than TV replacement. For example, there is a European registry of the Edwards Pascal tricuspid clip (NCT05328284), and a clinical evaluation of the Abbott tricuspid clip system has recently been published.⁵ A comprehensive review published in 2020 outlined some of the emerging technologies for the TV (Figure 2).⁶ It appears that the once “forgotten valve” has been rediscovered.

References

1. Nath J, Foster E, Heidenreich PA. Impact of tricuspid regurgitation on long-term survival. J Am Coll Cardiol. 2004;43:405-409. doi:10.1016/j.jacc.2003.09.036

2. Lindman BR, Maniar HS, Jaber WA, et al. Effect of tricuspid regurgitation and the right heart on survival after transcatheter aortic valve replacement: insights from the placement of aortic transcatheter valves II inoperable cohort. Circ Cardiovasc Interv. 2015;8(4):10.1161/CIRCINTERVENTIONS.114.002073 e002073. doi:10.1161/CIRCINTERVENTIONS.114.002073

3. Webb JG, Chuang AM, Meier D, et al. Transcatheter tricuspid valve replacement with the EVOQUE system: 1-year outcomes of a multicenter, first-in-human experience. JACC Cardiovasc Interv. 2022;15(5):481-491. doi:10.1016/j.jcin.2022.01.280

4. Kodali S, Hahn RT, George I, et al. Transfemoral tricuspid valve replacement in patients with tricuspid regurgitation: TRISCEND study 30-day results. JACC Cardiovasc Interv. 2022;15(5):471-480. doi:10.1016/j.jcin.2022.01.016

5. Lurz P, Stephan von Bardeleben R, Weber M, et al. Transcatheter edge-to-edge repair for treatment of tricuspid regurgitation. J Am Coll Cardiol. 2021;77(3):229-239. doi:10.1016/j.jacc.2020.11.038

6. Chung CJ, George I. Emerging transcatheter therapies for tricuspid valve disease. JTCVS Open. 2020;2:14-19. doi:10.1016/j.xjon.2020.04.003