Transcatheter Tricuspid Valve Replacement

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Key points

  • Tricuspid valve-in-valve procedures demonstrate good results and can be performed in a relatively straightforward manner.

  • Tricuspid valve-in-ring procedures demonstrate reasonable efficacy, but operators should be facile in treating paravalvular leak which is common after the ViR procedure.

  • Newer technologies and device development for replacement of native tricuspid valve pathology are under development and investigation, though none are currently available for commercial use.

Patient selection

Appropriate patient selection is a key element for all invasive procedures. In contemporary surgical practice, patients undergoing surgery for coronary artery bypass or other valve disease often undergo concomitant TVRe in the setting either of severe TR, or if the annulus is dilated >40 mm, as a preemptive strategy. This scenario represents the majority (87%) of TV surgical procedures. Conversely, isolated TVRe is rarer, constituting 13% of TV surgeries.1

This surgical practice of “incidental”

Valve-in-ring replacement for prior tricuspid valve repair

As noted in earlier discussion, several patients undergo TV ring repair in the setting of symptomatic severe TR or incidentally as part of another cardiac surgery in selected situations. In recent years, approximately 9000 patients undergo TV surgery annually.6 As noted previously, almost 90% of those surgeries are repairs. The surgical literature has been reasonably consistent in demonstrating the superiority of ring annuloplasty over suture-based techniques alone with regard to TR recurrence.7

Valve-in-valve replacement for bioprosthetic tricuspid valve degeneration

Just less than 1000 patients in the United States undergo TVR using a bioprosthesis placement annually.6 Although TVre using ring annuloplasty is the favored approach, those patients whose valve is too remodeled for repair have significant leaflet tethering or severe right ventricular dilation, or who have failed prior TVre may require TVR.11 An accurate estimate of TVR longevity is difficult to know, because “freedom from reoperation” statistics likely underestimate the true incidence of valve

Native tricuspid valve disease

As discussed earlier, native TV regurgitation is usually treated in patients undergoing cardiac surgery for other reasons, whether the regurgitation is severe or if it is moderate with evidence of TV annulus dilation. On the other hand, isolated TV surgery is relatively rare, especially for those patients who develop severe and symptomatic TR at some point after prior cardiac surgery. Among patients who do undergo isolated TV surgery, whether as a first-time operation or as a re-do, operative

Summary

Patients with significant tricuspid disease, whether native valve, with prior TV ring annuloplasty, or within a prior TV replacement often present with significant symptoms but may not be ideal candidates for operation or reoperation. As always, it will be important to develop a better understanding of which patients can be helped and which patients may be beyond help as a result of poor right-sided mechanics or comorbid conditions. Although there are limitations to the currently available

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