Clinical Images

Transcatheter Tricuspid Repair With MitraClip for Severe Primary Tricuspid Regurgitation

Neil P. Fam, MD, MSc1;  Kim A. Connelly, MD, PhD1;  Christoph Hammerstingl, MD2;  Geraldine Ong, MD1;  Anthony W. A. Wassef, MD1;  Heather J. Ross, MD, MHSc3;  Subodh Verma, MD, PhD4

Neil P. Fam, MD, MSc1;  Kim A. Connelly, MD, PhD1;  Christoph Hammerstingl, MD2;  Geraldine Ong, MD1;  Anthony W. A. Wassef, MD1;  Heather J. Ross, MD, MHSc3;  Subodh Verma, MD, PhD4

Abstract: Severe tricuspid regurgitation is an independent predictor of adverse outcomes, yet few patients undergo surgery and treatment with medical therapy is often inadequate. Recent studies have reported the use of the MitraClip system (Abbott Vascular) to treat secondary tricuspid regurgitation. We describe the first use of MitraClip to treat severe primary tricuspid regurgitation and right heart failure in a patient with previous cardiac transplantation and high surgical risk.

J INVASIVE CARDIOL 2016;28(12):E223-E224.

Key words: tricuspid regurgitation, heart failure, new technique


Although the majority of patients have secondary tricuspid regurgitation (TR), a significant proportion have primary TR related to rheumatic or degenerative disease, or iatrogenic causes such as pacemaker/implantable cardioverter-defibrillator leads and right ventricular biopsies. Early experience with transcatheter tricuspid valve repair (TTVR) for secondary TR with MitraClip (Abbott Vascular) has been recently reported.1,2 Here, we report the first use of MitraClip to treat severe primary TR. 

Case Presentation

A 52-year-old man presented with recurrent right heart failure despite optimal medical therapy. He had undergone cardiac transplantation 3 years prior for ischemic cardiomyopathy and past history included atrial fibrillation, pulmonary embolism, stroke, and chronic kidney disease. Transesophageal echocardiography revealed a dilated right ventricle with preserved function, severe TR with annular dilatation, and a perforated posterior tricuspid leaflet with a torn chord and flail segment, presumably from previous endomyocardial biopsy. Left ventricular size and function were normal, with mild mitral regurgitation. The patient was reviewed by the heart team and deemed at high risk for surgery, so a plan was made for transcatheter repair with MitraClip using a transfemoral approach. 

The initial strategy was to target the posterior leaflet flail segment. The posterior and anterior leaflets were successfully grasped at their tips, but this did not impact TR severity and so were released. The posterior and septal leaflets could not be grasped due to the posterior leaflet perforation. Subsequently, we targeted the anterior and septal leaflets. The first clip was placed at the base of the leaflets, while the second clip was placed close to the leaflet tips, with an acute reduction in TR by one grade (Figure 1, Video 1). The patient remained stable and was discharged 2 days later. At 30-day follow-up, the patient reported functional improvement to New York Heart Association class II, with 5 kg weight loss and less peripheral edema. Transthoracic echocardiography demonstrated reduction of TR into the moderate range (Figure 2), with right ventricular reverse remodeling and increased left ventricular stroke volume.

The MitraClip system offers the possibility to treat primary, secondary, and mixed etiologies of TR, a potential advantage over other devices. Future device iterations with longer clip arms and modified grippers will likely allow for more effective treatment of TR. Although early results of transcatheter tricuspid intervention are promising, randomized trials compared to medical therapy are needed to demonstrate long-term efficacy and safety, along with improvements in quality of life and reduction in heart failure hospitalizations.

References

1.    Hammerstingl C, Schueler R, Malasa M, et al. Transcatheter treatment of severe tricuspid regurgitation with the MitraClip system. Eur Heart  J. 2016;37:849-853.

2.    Schofer J, Tiburtius C, Hammerstingl C, et al. Transfemoral tricuspid valve repair using a percutaneous mitral valve repair system. J Am Coll Cardiol. 2016;67:889-890.


From the 1Division of Cardiology, St. Michael’s Hospital, Toronto, Ontario, Canada; 2Medizinische Klinik und Poliklinik II, Universitätsklinikum Bonn, Bonn, Germany; 3Division of Cardiology, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada; and 4Division of Cardiac Surgery, St. Michael’s Hospital, Toronto, Ontario, Canada.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Connelly reports speaker fees from Abbott Vascular. The remaining authors report no conflicts of interest regarding the content herein.

Manuscript submitted June 8, 2016, provisional acceptance given June 14, 2016, final acceptance given June 24, 2016.

Address for correspondence: Neil P. Fam, MD, MSc, FRCPC, Division of Cardiology, St. Michael’s Hospital, 30 Bond St, Toronto, ON M5B 1W8, Canada. Email: famn@smh.ca

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