Key trends in transcatheter tricuspid valve repair and replacement
The transcatheter treatment of tricuspid valve disease has rapidly evolved over the past two years, giving physicians new tools to address a condition long considered undertreated due to limited procedural options and complex anatomy. Ryan K. Kaple, MD, director of the structural and congenital heart program at Hackensack University Medical Center, spoke to Cardiovascular Business about recent advances in this area and his own's center's real-world experience.
Kaple said the commercial availability of transcatheter repair and replacement technologies has made a major impact on patient care.
“We never had anything previously for the tricuspid valve space from a percutaneous perspective,” Kaple said. “But now we have the TriClip from Abbott, which is a repair device, and we have the Evoque replacement valve from Edwards. Both have really been game-changers for us in terms of our ability to actually finally treat these patients with tricuspid valve disease.”
Hackensack also offers a bicaval valve approach for patients with severe symptomatic tricuspid regurgitation who may not be ideal candidates for other therapies through the TRICAV-I Trial evaluating the TricValve system. This systems uses two valves, one placed in the inferior and superior vena cava, to reduce venous congestion by limiting backflow from the right atrium.
Although early device trials of tricuspid interventions did not demonstrate statistically significant mortality benefits, Kaple said quality-of-life (QOL) improvements were substantial. Those data ultimately led to U.S. Food and Drug Administration (FDA) approvals.
“Some of the most impactful procedures I've done for my patients are the QOL improvement in people with a tricuspid regurgitation, especially if they have significant ascites in the abdomen or lower extremity edema. That is an incredibly meaningful thing for quality of life to get rid of those symptoms,” Kaple explained.
Expanded research and real-life experience has led to a better understanding of how right ventricular function and pulmonary artery pressures influence outcomes after tricuspid intervention. For this reason, Kaple said his team is working closely with heart failure specialists who are using the implantable CardioMEMS pulmonary artery pressure monitoring system to monitor for changes in heart failure status. He said the device can also help monitor tricuspid pressures before and after procedures.
“We are getting better at understanding how to assess right ventricular function and what symptoms are reversible,” Kaple said. “And I think as we get better at patient selection ... that's when we start to really see incremental gains in terms of the benefit to the patient directly.”
Imaging remains a major challenge in the tricuspid space, particularly in patients with prior cardiac surgery or pacemaker leads. Kaple said Hackensack uses a multimodality approach that includes transesophageal echocardiography (TEE), high-resolution multiphase CT, intracardiac echo (ICE) and CT-fluoroscopy fusion during procedures.
Managing patients with pacemaker or defibrillator leads crossing the tricuspid valve requires a tailored strategy, Kaple added. This may include lead extraction or just working around the lead during repair.
When it comes to procedural goals, eliminating all regurgitation is not always necessary. Even some reduction in regurgitation can improve the QOL of a patient. Kaple emphasized that there is a need to balance symptom improvement with the right ventricle’s ability to tolerate increased afterload.
“We do know from some of the repair trials that getting down to moderate [regurgitation] is in most patients tolerated and probably the best in terms of improving the symptoms maximally,” he said. “So it's a balance.”
Dave Fornell has covered healthcare for more than 17 years, with a focus in cardiology and radiology. Fornell is a 5-time winner of a Jesse H. Neal Award, the most prestigious editorial honors in the field of specialized journalism. The wins included best technical content, best use of social media and best COVID-19 coverage. Fornell was also a three-time Neal finalist for best range of work by a single author. He produces more than 100 editorial videos each year, most of them interviews with key opinion leaders in medicine. He also writes technical articles, covers key trends, conducts video hospital site visits, and is very involved with social media. E-mail: [email protected]