Percutaneous Transfemoral Tricuspid Valve Edge-to-Edge Repair

• comorbidity
• echocardiography, transesophageal
• heart failure
• mitral valve
• tricuspid
• valve insufficiency

Recently, transcatheter treatment of the tricuspid valve was reported as an interventional approach for severe tricuspid regurgitation (TR).¹ From May 2016 to January 2017, 8 patients underwent percutaneous transfemoral tricuspid valve edge-to-edge repair using the MitraClip system (Abbott Vascular) as recommended by our interdisciplinary heart team. The patient characteristics and procedural data are described in Table. All patients experienced severe TR and had relevant comorbidities. In 6 out of 8 patients, at least one clip could be placed; in 5 out of these 6 patients, TR could be reduced at least by 1.5 grades. In 4 out of 8 patients, we applied intracardiac echocardiography (ICE) as an additional imaging modality because visualization of the tricuspid valve is a crucial point in this procedure. In the following paragraphs, we describe one of these cases supported by ICE.

A 78-year-old patient presented with right heart failure symptoms caused by severe TR (Figure [A]). Four years ago, percutaneous edge-to-edge mitral valve repair was performed with reduction of MR to grade I–II (Figure [A]). Intraprocedural transesophageal echocardiography revealed that the main TR regurgitation jet was located between the anterior and the septal leaflet of the tricuspid valve (Figure [A and B]). The clip was positioned underneath the tricuspid valve plane, then rotation and position of the clip were adjusted using transesophageal echocardiography (Figure [C and D]). Because imaging of leaflet insertion and adjustment of clip alignment by transesophageal echocardiography guidance was not sufficient, we decided to perform additional ICE. An ICE probe (ViewFlex Plus ICE Catheter; St Jude Medical) was advanced into the right atrium (Figure [D and E]). Using ICE guidance, we could visualize that sufficient leaflet material was caught by the clip (Figure [F through H]). Interestingly, we generated a double orifice–like morphology (Figure [I]). When we deployed the clip (Figure [J]), we achieved a strong reduction of TR as confirmed by ICE and conventional transesophageal echocardiography (Figure [K and L]).

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Figure.

Images of intracardiac echocardiography (ICE), fluoroscopy, and transesophageal echocardiography (TOE) during percutaneous edge-to-edge tricuspid valve repair. A and B, TOE revealed severe tricuspid valve regurgitation between the anterior and the septal leaflet (A, 4-chamber view and B, transgastric view). C and D, TOE view and fluoroscopic anteroposterior (AP) view verifying correct clip rotation, ICE catheter indicated by →. E, ICE confirmed severe tricuspid regurgitation. F–H, View provided by the ICE catheter to support guidance of the grasping maneuver and verify leaflet insertion. I, Double orifice after clip deployment as visualized by TOE. J, Fluoroscopic AP view after clip deployment. K, View provided by ICE showing residual TR after clip deployment. L, Residual mild TR in TOE 4-chamber view. A indicates anterior leaflet; c, clip; P, posterior leaflet; and S, septal leaflet. #Artifact; *Clip arms.

In conclusion, edge-to-edge tricuspid valve repair is a novel option for patients with severe TR not eligible for conventional surgery. There are, however, limitations to this approach such as limited visualization of the valve, feasibility of the procedure as determined by the underlying pathology, and lack of profound experience. Future studies would have to further scrutinize the value of the edge-to-edge tricuspid valve repair.

• Received February 20, 2017.
• Accepted March 1, 2017.

• © 2016 American Heart Association, Inc.