Transcatheter tricuspid valve annuloplasty for tricuspid regurgitation

The condition

2.1 Tricuspid regurgitation happens when the tricuspid valve does not close properly during systole and blood flows backwards through the valve. It can be caused by a problem with the valve itself (primary), but it is more commonly secondary to an underlying cardiac problem that has caused the heart to become dilated. This has the effect of stretching the annulus that supports the valve leaflets to such an extent that the leaflets do not meet and regurgitation of blood happens.

2.2 People with mild tricuspid regurgitation do not usually have any symptoms. If the regurgitation is severe people may have fatigue and weakness, active pulsing in the neck veins, liver enlargement, ascites, peripheral oedema and renal impairment. Pulmonary hypertension may develop.

Current treatments

2.3 Treatment may not be needed if there are no or mild symptoms. Symptoms of heart failure are managed with diuretics and other medicines. Medication to reduce pulmonary artery pressure or pulmonary vascular resistance, or both, is used for severe functional tricuspid regurgitation and severe pulmonary hypertension.

2.4 People with severe symptoms may have surgery to repair or replace the tricuspid valve. Isolated tricuspid valve surgery is rarely done. More commonly, it is done at the same time as surgery to the valves on the left side of the heart (mitral and aortic).

The procedure

2.5 Transcatheter tricuspid valve annuloplasty is designed to improve the function of the tricuspid valve with less morbidity and mortality than conventional surgical annuloplasty. It has been proposed as an option for people in whom conventional open surgery poses a high risk. The procedure aims to reduce regurgitation, increase quality of life, and reduce hospital admissions related to heart failure.

2.6 The procedure is done under general anaesthesia using transoesophageal echocardiography and fluoroscopy guidance. Access to the heart is through the femoral or jugular vein.

2.7 Different systems have been used and details of the technique vary. In one example, an annuloplasty ring or band is delivered through a catheter and implanted around the circumference, or annulus, of the tricuspid valve. A size adjustment tool is used to contract the device, which reduces the tricuspid annular diameter and brings the valve leaflets together. When the appropriate amount of reduction has been achieved, the implant is detached from the delivery system, which is then removed. In other systems, sutures are used to either exclude the posterior leaflet and create a functional bicuspid valve or to reduce the area of the tricuspid annulus. Adequate reduction of tricuspid regurgitation is assessed using echocardiography.