Praz, Fabien

Sticchi, Alessandro

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Heterotopic Transcatheter Tricuspid Valve Implantation: A Useful Bailout Strategy After Failed Transcatheter Tricuspid Valve Repair?

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J A C C : C A S E R E P O R T S V O L . 4 , N O . 1 6 , 2 0 2 2ª 2 0 2 2 T H E A U T HO R S . P U B L I S H E D B Y E L S E V I E R O N B E H A L F O F T H E A M E R I C A NC O L L E G E O F C A R D I O L O G Y F O U N DA T I O N . T H I S I S A N O P E N A C C E S S A R T I C L E U N D E RT H E C C B Y - N C - N D L I C E N S E ( h t t p : / / c r e a t i v e c o mm o n s . o r g / l i c e n s e s / b y - n c - n d / 4 . 0 / ) .EDITORIAL COMMENTHeterotopic Transcatheter TricuspidValve ImplantationA Useful Bailout Strategy After Failed TranscatheterTricuspid Valve Repair?*Alessandro Sticchi, MD,a Fabien Praz, MDbI n this issue of JACC: Case Reports, Costa et al1 re-ported an interesting case of caval valve implan-tation (CAVI) using the TricValve system (PþFProducts þ Features) as a bailout strategy followingunsuccessful tricuspid transcatheter edge-to-edgerepair (T-TEER) because of partial detachment of aTriClip XT (Abbott).The 71-year-old female patient had multivalvularrheumatic heart disease and underwent mitral valvereplacement because of mitral stenosis. As a secondstep, symptomatic aortic stenosis was treated withthe transfemoral implantation of a self-expandingtranscatheter valve.Following open heart surgery, worsening rightventricular (RV) dilatation and secondary tricuspidregurgitation (TR) have been observed in 31% of pa-tients with rheumatic heart disease.2 Redo surgicalprocedures to correct TR have been associatedwith excessive mortality, which is confirmed by acalculated TRI-SCORE of 7 of 12, predicting a risk ofin-hospital mortality of 34% in the presented pa-tient.3 In this context, transcatheter treatment of thetricuspid valve represents an appropriate and safeapproach.During the initial T-TEER procedure, detachmentof 1 of the 3 implanted clips occurred, leading toISSN 2666-0849*Editorials published in JACC: Case Reports reflect the views of the au-thors and do not necessarily represent the views of JACC: Case Reports orthe American College of Cardiology.From the aHumanitas Research Hospital IRCCS, Rozzano, Milano, Italy;and the bBern University Hospital, University of Bern, Bern, Switzerland.The authors attest they are in compliance with human studies commit-tees and animal welfare regulations of the authors’ institutions and Foodand Drug Administration guidelines, including patient consent whereappropriate. For more information, visit the Author Center.recurrent severe TR. With a prevalence ranging from3% to 7% in published studies,4,5 single-leaflet deviceattachment is a frequent complication during or earlyafter T-TEER, in particular in patients with subopti-mal imaging because of shadowing, as sometimesobserved in the presence of a mechanical mitral valveprosthesis. Previously described management strate-gies include stabilization using additional implants,conversion to surgery, transcatheter valve replace-ment, or caval valve implantation.6-8The device used in this patient, the TricValve sys-tem, consists of 2 self-expanding nitinol stents withbovine pericardial leaflets, each of them specificallydesigned to be implanted in the superior and theinferior vena cava with the aim of alleviatingcongestive symptoms. The 6-month results of theEuropean approval single-arm study, the TRICUSEURO (Safety and Efficacy of the TricValve Trans-catheter Bicaval Valves System in the Superior andInferior Vena Cava in Patients With Severe TricuspidRegurgitation) registry (12 centers), have been pub-lished recently and described good technical andprocedural success. Furthermore, the study reportedfunctional improvement (Kansas City Cardiomyopa-thy Questionnaire [KCCQ-12] score from 42.01  22.3points at baseline to 59.7  23.6 at 6 months[P ¼ 0.004]; patients in New York Heart Associationfunctional class I or II from 0% at baseline to 79.4% at6 months). Six-month all-cause mortality and heartfailure hospitalization rates were 8.5% and 20%,respectively.9Another dedicated caval valved stent, the Tri-cento system (New Valve Technology), is availablein Europe and has shown comparable performancein a recently published multicenter retrospectivestudy.10 Using cardiovascular magnetic resonancehttps://doi.org/10.1016/j.jaccas.2022.07.011FIGURE 1 Proposed Selection Criteria for Heterotopic Caval Valve ImplantationRA ¼ right atrial.J A C C : C A S E R E P O R T S , V O L . 4 , N O . 1 6 , 2 0 2 2 Sticchi and PrazA U G U S T 1 7 , 2 0 2 2 : 1 0 1 2 – 1 0 1 4 Heterotopic TTVI as Bailout Strategy After T-TEER1013imaging in a subgroup of patients, evidence of RVremodeling was observed at 6 months, while frac-tures of the custom-made stent have been detectedby systematic 4-dimensional computed tomographyand triggered changes in design and patient selec-tion criteria. Compared to the off-label use oftranscatheter aortic valves, dedicated caval systemsappear safer and less prone to dislocation.11Considering the technical complexity of trans-catheter tricuspid valve interventions with stilllimited expertise and availability, as well as thehigh dependency on sufficient imaging conditions,CAVI may represent a simple palliative treatmentalternative for patients with advanced right heartfailure and no other therapeutic option. Becausesymptomatic response is not uniformly observed,careful patient selection, including invasive hemo-dynamic assessment, is required (Figure 1). Resolu-tion of venous renal congestion (or “renaltamponade”) may represent one of the main path-ophysiologic mechanisms conditioning clinicalresponse, and therefore sufficient urine output mayplay a role in patients with severe or terminal renalfailure.12 Patients with failed T-TEER may beparticularly suitable because the valve is generallyno longer amenable to other treatment modalitiesdue to additional still attached clips (as in thepresent case), interaction with the detached device,or already increased transvalvular gradient.7,8Furthermore, the heterotopic position may allowfor a second intervention through the valved stent,if required.8,13,14As another interesting aspect, the presentedcase highlights the role of multimodality imagingduring work-up but also the use of computed to-mography fusion to identify the contours of theright atrium and the location of the hepatic veins,2 key anatomic landmarks during caval valveimplantation.15Against the background of the modest clinicalresponse and the risk of progression of RV dysfunc-tion discussed in the present case, further studies arecertainly needed to understand the exact role of CAVIin the emerging landscape of transcatheter tricuspidinterventions.FUNDING SUPPORT AND AUTHOR DISCLOSURESDr Sticchi has received travel expenses from Terumo. Dr Praz hasreceived travel expenses from Abbott Vascular, Edwards Lifesciences,and Polares Medical.ADDRESS FOR CORRESPONDENCE: Dr AlessandroSticchi, Cardio Center, IRCCS Humanitas ResearchHospital, Via Alessandro Manzoni 56, Rozzano, Milan20098, Italy. E-mail: sticchialessandro@gmail.com.Sticchi and Praz J A C C : C A S E R E P O R T S , V O L . 4 , N O . 1 6 , 2 0 2 2Heterotopic TTVI as Bailout Strategy After T-TEER A U G U S T 1 7 , 2 0 2 2 : 1 0 1 2 – 1 0 1 41014RE F E RENCE S1. Costa G, De Carlo M, Spontoni P, et al. Hetero-topic transcatheter tricuspid valve replacement insevere tricuspid regurgitation and refractory rightheart failure. J Am Coll Cardiol Case Rep. 2022;4:1005–1011.2. Chen Y, Chan Y-H, Wu M-Z, et al. Prevalenceand prognostic importance of massive tricuspidregurgitation in patients undergoing tricuspidannuloplasty with concomitant left-sided valvesurgery: a study on rheumatic valvular heart dis-ease. Front Cardiovasc Med. 2022;9:686208.3. Dreyfus J, Audureau E, Bohbot Y, et al. TRI-SCORE: a new risk score for in-hospital mortalityprediction after isolated tricuspid valve surgery.Eur Heart J. 2022;43(7):654–662.4. Nickenig G, Weber M, Lurz P, et al. Trans-catheter edge-to-edge repair for reduction oftricuspid regurgitation: 6-month outcomes ofthe TRILUMINATE single-arm study. Lancet.2019;394(10213):2002–2011.5. Kodali S, Hahn RT, Eleid MF, et al. Feasibilitystudy of the transcatheter valve repair System forsevere tricuspid regurgitation. J Am Coll Cardiol.2021;77(4):345–356.6. Wild MG, Zahr F, Näbauer M, Massberg S,Hausleiter J. Transfemoral transcathetertricuspid valve replacement after failed leafletrepair. EuroIntervention. 2021;17(12):E1022–E1023.7. Mattig I, Knebel F, Hewing B, et al. Impactof inferior caval valve implantation onseverity of tricuspid regurgitation and rightheart function. Echocardiography. 2020;37(7):999–1007.8. Rroku A, Barbieri F, Landmesser U, Skurk C,Kasner M, Reinthaler M. Transcatheter caval valveimplantation for tricuspid regurgitation aftersingle leaflet device attachment. J Am Coll CardiolCase Rep. 2022;4(8):481–485.9. Estévez-Loureiro R, Sánchez-Recalde A, Amat-Santos IJ, et al. Six-month outcomes of theTricValve system in patients with tricuspid regur-gitation: TRICUS EURO Study. J Am Coll CardiolIntv. 2022;15(13):1366–1377.10. Wild MG, Lubos E, Cruz-Gonzalez I, et al.Early clinical experience with the TRICENTObicaval valved stent for treatment of symptom-atic severe tricuspid regurgitation: a multicenterregistry. Circ Cardiovasc Interv. 2022;15(3):E011302.11. Dreger H, Mattig I, Hewing B, et al. Treatmentof severe TRIcuspid regurgitation in patients withadvanced heart failure with caval vein implanta-tion of the Edwards Sapien XT valve (TRICAVAL): arandomised controlled trial. EuroIntervention.2020;15(17):1506–1513.12. Boorsma EM, ter Maaten JM, Voors AA, vanVeldhuisen DJ. Renal compression in heart failure:the renal tamponade hypothesis. Heart Fail.2022;10(3):175–183.13. Altisent OAJ, Benetis R, Rumbinaite E, et al.Caval valve implantation (CAVI): an emergingtherapy for treating severe tricuspid regurgitation.J Clin Med. 2021;10(19):4601.14. Bartkowiak J, Boscolo M, Sticchi A,Brugger N, Hunziker L, Praz F. Combinedcaval valved stent implantation and leafletapproximation for treatment of torrentialtricuspid regurgitation. J Am Coll Cardiol Intv.2022;15(13):1384–1385.15. Praz F, Muraru D, Kreidel F, et al. Transcathetertreatment for tricuspid valve disease. Euro-Intervention. 2021;17(10):791–808.KEY WORDS computed tomography, imaging,tricuspid valve, valve replacement

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Heterotopic Transcatheter Tricuspid Valve Implantation: A Useful Bailout Strategy After Failed Transcatheter Tricuspid Valve Repair?

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