Transcatheter tricuspid valve repair: early experience in the Netherlands

Original Article Neth Heart J https://doi.org/10.1007/s12471-021-01613-3 Transcatheter tricuspid valve repair: early experience in the Netherlands F. Meijerink · K. T. Koch · R. J. de Winter · M. Holierook · B. J. W. M. Rensing · L. Timmers · F. D. Eefting · M. J. Swaans · B. J. Bouma · J. Baan Accepted: 6 July 2021 © The Author(s) 2021 Abstract Background Symptomatic tricuspid regurgitation (TR) is increasingly prevalent and impairs quality of life and survival, despite medical treatment. Transcatheter tricuspid valve repair (TTVR) has recently become available as a treatment option for patients not eligible for tricuspid valve surgery. In this study we describe the early experience with TTVR in the Netherlands. Methods All consecutive patients scheduled for TTVR in two tertiary hospitals were included in the current study. Patients were symptomatic and had severe functional TR. TTVR was performed either with the MitraClip (off-label use) or dedicated TriClip delivery system and device. Procedural success was defined as achievement of clip implantation, TR reduction ≥ 1 grade and no need for re-do surgical or transcatheter intervention. Clinical improvement was evaluated after 4 weeks. Results Twenty-one patients (median age 78 years, 33% male, 95% New York Heart Association class ≥ 3, 100% history of atrial fibrillation) underwent TTVR. Procedural success was achieved in 16 patients, of whom 15 reported symptomatic improvement (New B.J. Bouma and J. Baan share senior authorship. York Heart Association class 1 or 2). There was no in-hospital mortality and no major complications occurred. Baseline glomerular filtration rate and TR coaptation gap size were associated with procedural success. Conclusion The current study showed that TTVR seems a promising treatment option for patients with severe functional TR deemed high risk for surgery. Successful TR reduction is most likely in patients with limited coaptation gap size and strongly determines clinical benefit. Adequate patient selection and timing of treatment seem essential for an optimal patient outcome. Keywords Tricuspid regurgitation · Transcatheter treatment · Valvular heart disease · Echocardiography What’s new? Transcatheter tricuspid valve repair (TTVR) is now available for patients with symptomatic tricuspid regurgitation (TR) not eligible for valve surgery.  When TR reduction ≥ 1 grade can be established, clinical improvement is likely.  Coaptation gap size is the most important determinant of a successful procedure.  Patients with no significant left-sided heart valve disease, preserved right ventricular function, no pulmonary hypertension and a coaptation gap size < 10 mm should be considered for TTVR.  Supplementary Information The online version of this article (https://doi.org/10.1007/s12471-021-01613-3) contains supplementary material, which is available to authorized users. F. Meijerink · K. T. Koch · R. J. de Winter · M. Holierook · B. J. Bouma · J. Baan () Department of Cardiology, Amsterdam UMC, location AMC, Amsterdam, The Netherlands B. J. W. M. Rensing · L. Timmers · F. D. Eefting · M. J. Swaans Department of Cardiology, St Antonius Hospital, Nieuwegein, The Netherlands Transcatheter tricuspid valve repair: early experience in the Netherlands Original Article Fig. 1 a Tricuspid valve (TV) anatomy and most common clip locations (grey dots). Three-dimensional echocardiographic view of the TV b before and c after implantation of two clips on the anterior and septal leaflets. A anterior leaflet, P posterior leaflet, S septal leaflet Introduction Echocardiography Tricuspid regurgitation (TR) is as common as mitral regurgitation (MR) in the general population and its prevalence increases with age. Functional TR accounts for up to 90% of patients. Annular dilatation and increased tricuspid leaflet tethering in relation to right ventricular (RV) pressure and/or volume overload cause functional TR. Left-sided heart disease, atrial fibrillation (AF) or pulmonary hypertension are frequently involved in the pathogenesis of TR [1, 2]. Significant TR often leads to right-sided heart failure symptoms and is associated with increased morbidity and mortality [3]. Once TR is present, a vicious circle arises where TR begets more RV and right atrial (RA) dilatation, leading to more TR. Whilst tricuspid valve (TV) intervention is indicated when symptomatic TR is present, the risk of surgery is deemed to be too high in most patients with isolated TR due to the presence of RV dysfunction, advanced age or other (cardiac) co-morbidities [4]. Until recently, these patients could only be treated with medical therapy, but transcatheter tricuspid valve repair (TTVR) is now available. The aim of this study was to evaluate the early experience with TTVR in the Netherlands with a focus on patient selection, safety and effectiveness of the procedure as well as determinants of procedural success. TR severity was determined by transthoracic echocardiography (TTE) and graded according to the latest classification, including massive and torrential TR [5]. These additional grades are highly relevant, because patients often present with TR largely exceeding the guideline cutoff criteria for severe TR. Reduction to less than severe TR is not always achieved, but has appeared to be associated with improved outcome. Standard parameters were included according to the guidelines of the American Society for Echocardiography (ASE) and European Association of Cardiovascular Imaging (EACVI) [6, 7]. Methods Study population All consecutive patients who underwent TTVR at Amsterdam University Medical Centre, location AMC, Amsterdam and St Antonius Hospital, Nieuwegein between October 2019 and February 2021 were included. Patients were admitted via the heart team and screened by a dedicated transcatheter valve intervention team. In all patients, the risk of TV surgery was deemed to be too high. All patients consented to participation and the study was conducted in accordance with the Declaration of Helsinki. Procedure TTVR was performed using the clip-based edge-toedge technique with the MitraClip device (Abbott, Santa Clara, CA, USA) as off-label use in 13 patients. The dedicated TriClip device (Abbott) has been available for clinical use in the Netherlands since September 2020 and was used in 8 patients [8]. Major improvements offered by the TriClip device include (1) extended flexion of the guiding catheter, which provides improved height adjustment above the valve and (2) improved motion in septal and lateral directions, which increases the reach when placing clips in the antero-septal (AS) and postero-septal (PS) commissures, allowing more complex jets to be treated. Figure S1 (see Electronic Supplementary Material) shows both systems and the specific differences. After obtaining access to the femoral vein, the guiding catheter was introduced. The clip delivery system was subsequently inserted into the guiding cathet (...truncated)