How are you taking part in this consultation?

You will not be able to change how you comment later.

You must be signed in to answer questions

    The content on this page is not current guidance and is only for the purposes of the consultation process.

    Interventional procedure overview of transcatheter tricuspid valve annuloplasty for tricuspid regurgitation

    Closed for comments This consultation ended on at   Request commenting lead permission

    Description of the procedure

    Indications and current treatment

    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 stretches the annulus that supports the valve leaflets to such an extent that the leaflets do not meet and regurgitation of blood happens. 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.

    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.

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

    What the procedure involves

    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.

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

    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.

    Outcome measures

    New York Heart Association (NYHA) functional class

    The NYHA functional class is used to classify heart failure according to severity of symptoms and limitation of physical activity:

    • Class 1 - no limitation of physical activity. Ordinary physical activity does not cause undue fatigue, breathlessness, or palpitations.

    • Class 2 - slight limitation of physical activity. Comfortable at rest but ordinary physical activity results in undue breathlessness, fatigue, or palpitations.

    • Class 3 - marked limitation of physical activity. Comfortable at rest but less than ordinary physical activity results in undue breathlessness, fatigue, or palpitations.

    • Class 4 - unable to carry out any physical activity without discomfort. Symptoms at rest can be present. If any physical activity is undertaken discomfort is increased.

    Kansas City Cardiomyopathy Questionnaire

    The Kansas City Cardiomyopathy Questionnaire is a 23-item self-administered questionnaire that measures the patient's perception of their health status, including heart failure symptoms, impact on physical and social function, and how their heart failure impacts their quality of life within a 2-week recall period. Scores are scaled from 0 to 100, where higher scores represent better health status.