What is Orthotopic TTVR?

TTVR stands for transcatheter tricuspid valve replacement. Orthotopic TTVR involves implantation of the prosthetic valve within the native tricuspid valve annulus. Heterotopic TTVR is placement of a prosthetic valve in the inferior or superior vena cava, which is a less invasive palliative procedure for severe tricuspid regurgitation. Orthotopic TTVR aims at complete elimination of TR, but the procedure is limited by complex anatomy of the tricuspid valve and large coaptation gaps. Orthotopic TTVR mimics conventional surgical tricuspid valve replacement. Devices can use radial force against tricuspid valve annulus for anchoring or anchor to the leaflets, septal wall or vena cava to stabilize the valve. Heterotopic TTVR is considered for palliation of symptoms of venous congestion when patients are not candidates for orthotopic TTVR or Tricuspid Transcatheter Edge-to-Edge Repair (T-TEER).

T-TEER is a minimally invasive procedure using clips to bring tricuspid valve leaflets together reducing TR. Heterotopic TTVR Can be used when orthotopic TTVR is anatomically impossible due to severe leaflet tethering or large coaptation gaps. Presence of cardiac implantable electronic device (CIED) leads is another problem while considering orthotopic TTVR. In that case, lead could be a cause of TR or an ‘innocent bystander’. Lead entrapment is likely during orthotopic TTVR, which may demand lead extraction and associated risks. Options after lead extraction for pacing could be leadless pacing or pacing from alternative sites without interfering the tricuspid valve. Both orthotopic TTVR and T-TEER are now approved in the USA and Europe [1].

Reference

1. Madhavan MV, Agarwal V, Hahn RT. Transcatheter Therapy for the Tricuspid Valve: A Focused Review of Edge-to-Edge Repair and Orthotopic Valve Replacement. Curr Cardiol Rep. 2024 Jun;26(6):459-474. doi: 10.1007/s11886-024-02051-4. Epub 2024 Jun 17. PMID: 38884853; PMCID: PMC11199311.