Transcatheter edge-to-edge repair (TEER) of the tricuspid valve

Transcatheter edge-to-edge repair (TEER) of the tricuspid valve

After transcatheter edge-to-edge repair (TEER) for mitral valve, TEER for tricuspid valve is catching up. Data from the United States of America has been published in May 2022. They queried the Nationwide Readmissions Database and identified 918 hospitalizations for TEER of tricuspid valve from 2016 to 2019. There was a rise from 13 cases in the first quarter of 2016 to 122 cases in the last quarter of 2019. Concomitant TEER of mitral valve was performed in 42.1% of the admissions.

Overall in-hospital mortality was 2.1% and surgical tricuspid valve replacement was needed in 1.1% of admissions; none of them died during the index hospitalization. 30 day unplanned rehospitalization was 15.7%. 38.2% of these re-hospitalizations were due to heart failure. There was no difference in in-hospital mortality between isolated TEER of tricuspid valve and combined mitral and tricuspid valve TEER. However, the length of hospital stay and urgent readmission rate was lower in those who received the combined procedure.

A single centre study in 2020 had reported on combined mitral and tricuspid valve TEER. They had 22 cases, performed with mean procedure time of 176 minutes and mean fluoroscopy time of 65 minutes. Mean procedure time was 223 minutes in the first tertile vs 143 minutes in the third tertile, indicating a learning curve. Median number of total clips placed per case was 3. In 15 patients, anterior and septal leaflets of the tricuspid valve were clipped [2].

There was significant trend toward decreasing residual tricuspid regurgitation over the course of the series. Thirty day survival in this series was 100% and mean NYHA class decreased from 2.8 to 1.8. At the time of the study from 2017 to 2019, TEER of tricuspid valve was an off-label use and this was a retrospective review.

A comparison of tricuspid and mitral vs mitral valve TEER from the TriValve (Transcatheter Tricuspid Valve Therapies)  and TRAMI (Transcatheter Mitral Valve Interventions) registries was also published in 2020. In TRAMI registry, 106 patients underwent isolated TEER of mitral valve. The 122 patients in TriValve registry underwent concurrent TEER of tricuspid valve in compassionate and/or off-label use. 93.9% patients were in New York Heart Association functional class III or IV [3].

Patients in the TEER of mitral valve group had more severe left ventricular dysfunction while more of those in the combined group had more of reduced glomerular filtration rates. On multivariate analysis, combined procedure was associated with a two fold lower mortality rate at one year. So there is a case for combined procedure and need for a randomized trial to confirm this aspect. Rate of patients in NYHA functional class II or less at one year was similar in both groups.

All these studies addressed the observation that residual tricuspid regurgitation is a predictor of adverse outcome after TEER of mitral valve. Another study published in 2018 with 61 patients of which 27 had combined procedure also came to similar conclusions as the other studies discussed. Effective regurgitant orifice area of tricuspid regurgitation was reduced from 0.51 sq. cm to 0.29 sq. cm after concomitant TEER of tricuspid valve while it was unchanged after TEER of mitral valve alone [4].

After up to 18 months of follow up, patients with combined procedure had fewer hospitalizations for heart failure. Death rates were comparable between the groups in that study. They also documented superior improvement in NYHA functional class, NT-proBNP levels and 6 minute walking distance for the combined procedure [4].

TRILUMINATE trial had 85 patients and was published in 2021. At one year tricuspid regurgitation was reduced to moderate or less in 71% compared to 8% at baseline. There was significant improvement in NYHA functional class and reverse right ventricular remodeling as well [5].

PASTE investigators reported tricuspid TEER in a total of 235 high risk patients in 2022. Mean Society of Thoracic Surgeons Predicted Risk of Mortality score was 8.6%. Tricuspid regurgitation was functional in 87% and severe or higher in 91%. Procedural success was 78% and tricuspid regurgitation was reduced to moderate or less in 78% of patients and was sustained at a median follow up of 173 days. 63% were in NYHA functional class I or II at follow up [6].

References

1. Sedhom R, Megaly M, Saad M, Elbadawi A, Witzke CF, Garcia S, Latib A, Gafoor SA. Transcatheter edge-to-edge repair of the tricuspid valve: The US experience. Catheter Cardiovasc Interv. 2022 May;99(6):1859-1866. doi: 10.1002/ccd.30141. Epub 2022 Apr 1. PMID: 35362665.
2. Mahowald MK, Pislaru SV, Reeder GS, Padang R, Michelena HI, Mankad SV, Maalouf JF, Guerrero M, Alkhouli M, Rihal CS, Eleid MF. Institutional learning experience for combined edge-to-edge tricuspid and mitral valve repair. Catheter Cardiovasc Interv. 2020 Nov;96(6):1323-1330. doi: 10.1002/ccd.28856. Epub 2020 Mar 17. PMID: 32180349.
3. Mehr M, Karam N, Taramasso M, Ouarrak T, Schneider S, Lurz P, von Bardeleben RS, Fam N, Pozzoli A, Lubos E, Boekstegers P, Schillinger W, Plicht B, Eggebrecht H, Baldus S, Senges J, Maisano F, Hausleiter J; TriValve and TRAMI Investigators. Combined Tricuspid and Mitral Versus Isolated Mitral Valve Repair for Severe MR and TR: An Analysis From the TriValve and TRAMI Registries. JACC Cardiovasc Interv. 2020 Mar 9;13(5):543-550. doi: 10.1016/j.jcin.2019.10.023. Epub 2020 Jan 15. PMID: 31954679.
4. Besler C, Blazek S, Rommel KP, Noack T, von Roeder M, Luecke C, Seeburger J, Ender J, Borger MA, Linke A, Gutberlet M, Thiele H, Lurz P. Combined Mitral and Tricuspid Versus Isolated Mitral Valve Transcatheter Edge-to-Edge Repair in Patients With Symptomatic Valve Regurgitation at High Surgical Risk. JACC Cardiovasc Interv. 2018 Jun 25;11(12):1142-1151. doi: 10.1016/j.jcin.2018.04.010. PMID: 29929635.
5. Lurz P, Stephan von Bardeleben R, Weber M, Sitges M, Sorajja P, Hausleiter J, Denti P, Trochu JN, Nabauer M, Tang GHL, Biaggi P, Ying SW, Trusty PM, Dahou A, Hahn RT, Nickenig G; TRILUMINATE Investigators. Transcatheter Edge-to-Edge Repair for Treatment of Tricuspid Regurgitation. J Am Coll Cardiol. 2021 Jan 26;77(3):229-239. doi: 10.1016/j.jacc.2020.11.038. PMID: 33478646.
6. Wild MG, Löw K, Rosch S, Gerçek M, Higuchi S, Massberg S, Näbauer M, Rudolph V, Markovic S, Boekstegers P, Rassaf T, Luedike P, Geisler T, Braun D, Stolz L, Praz F, Lurz P, Hausleiter J; PASTE Investigators. Multicenter Experience With the Transcatheter Leaflet Repair System for Symptomatic Tricuspid Regurgitation. JACC Cardiovasc Interv. 2022 Jul 11;15(13):1352-1363. doi: 10.1016/j.jcin.2022.05.041. PMID: 35798479.