JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY

VOL. 67, NO. 7, 2016

ª 2016 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION

ISSN 0735-1097/$36.00

PUBLISHED BY ELSEVIER

Letters Transfemoral Tricuspid Valve Repair Using a Percutaneous Mitral Valve Repair System

repair therapy might potentially also be applied for TR. A 77-year-old woman presented with increasing dyspnea and signs of right heart failure in New York Heart Association functional class III. Within the past 6 months, she had several hospital admissions despite intensive diuretic therapy. Her medical history included severe chronic obstructive pulmonary fibrillation.

There is increasing evidence that severe tricuspid

disease

regurgitation (TR) is associated with a poor prognosis.

revealed severe TR. The right ventricle was enlarged

Recently, less invasive transcatheter tricuspid repair

(43

technologies are emerging as alternative therapeutic

(tricuspid annular plane systolic excursion 27 mm).

options for high surgical risk patients. One percuta-

Systolic pulmonary artery pressure was 50 mm Hg,

neous mitral valve repair system (MitraClip, Abbott

and the left ventricular ejection fraction was normal

Vascular, Santa Clara, California) has demonstrated

with moderate MR.

and

mm)

atrial

with

preserved

Echocardiography

ventricular

function

safety and long-term clinical benefit. Very similar to

Based on the heart team’s discussion, the surgical

functional mitral regurgitation (MR), TR is mainly due

risk for this patient was unacceptably high. The patient

to ventricular enlargement, annulus dilation, and loss

gave her written informed consent for the procedure

of leaflet coaptation. Thus, percutaneous mitral valve

on the basis of a compassionate use of the device.

F I G U R E 1 Percutaneous Mitral Valve Repair Therapy for Tricuspid Regurgitation

(A) Three-dimensional transesophageal echocardiography and 2-dimensional color Doppler at baseline. (B) Three-dimensional transesophageal echocardiography and 2-dimensional Doppler after percutaneous mitral valve repair system (arrow) implantation.

890

JACC VOL. 67, NO. 7, 2016

Letters

FEBRUARY 23, 2016:889–94

The procedure was performed with the patient

When considering the percutaneous mitral valve

under general anesthesia with access from the right

repair system for tricuspid valve repair, several

femoral vein. The 24-F steerable guide catheter was

requirements must be met: 1) a large right atrium

positioned over a stiff guidewire into the right atrium.

for guide catheter steering; 2) sufficient coaptation

The guide catheter was then slightly pulled back, and

to get enough tissue for the (first) clip; 3) good

the tip was flexed. Thereafter, the clip was advanced

echocardiographic visibility, which is crucial and

forward until the bullet nose protruded from the tip of

might be a problem in the presence of valve pros-

the guide catheter. The clip was positioned perpen-

thesis or severe calcification of the mitral annulus;

dicular to the tricuspid valve by anterior movement

4) avoiding deep diving into or extensive move-

and bending of the guide catheter. Using deep trans-

ments of the clip in the right ventricle to prevent

gastric mid- and deep esophageal 2- and 3-dimensional

chordae rupture.

transesophageal echocardiography views, the appro-

This is the first description of a new interventional

priate clip arm orientation was adjusted, the clip was

approach for transfemoral tricuspid repair using the

advanced into the right ventricle slightly under the

percutaneous mitral valve repair system. Larger

leaflets, which were then captured. After implantation of a single clip, TR was reduced from severe to mild (Figure 1). At discharge, the

studies are required to confirm the feasibility, safety, and efficacy of the percutaneous mitral valve repair therapy in patients with severe TR.

patient’s symptoms significantly improved, transthoracic echocardiography demonstrated a stable clip position and sustained reduction of TR. We report the first transfemoral implantation of the MitraClip in a tricuspid valve with severe functional TR that resulted in a significant TR reduction. Therapeutic options for those patients are limited. Therefore, less invasive and safer therapeutic solutions are needed for this ever-growing patient population. A few transcatheter-based treatment options for TR are currently under evaluation. Laule et al. (1) reported on 3 patients with single or dual implantation with the SAPIEN XT prosthesis (Edwards Lifesciences, Irvine, California) for severe TR. This approach does not address TR itself, but may reduce the regurgitation of blood into the vena cava. With

*Joachim Schofer, MD, PhD Claudia Tiburtius, MD Christoph Hammerstingl, MD Per-Olof Dickhaut, MD Julian Witt, MD Lorenz Hansen, MD Friedrich-Christian Riess, MD, PhD Klaudija Bijuklic, MD *Albertinen Heart Center Süntelstrasse 11a 22457 Hamburg, Germany E-mail: [email protected] http://dx.doi.org/10.1016/j.jacc.2015.11.047 Please note: Dr. Hammerstingl has received honoraria from Abbott, Mitralign, and Valtech for serving as a proctor. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

improvement in 2- and 3-dimensional TEE, advanced imaging of the tricuspid valve became possible.

REFERENCES

Targeting malcoaptation, the results of 7 high-risk

1. Laule M, Stangl V, Sanad W, et al. Percutaneous transfemoral management of severe secondary tricuspid regurgitation with Edwards Sapien XT bio-

patients with severe TR who received the Forma Repair System (Edwards Lifesciences) were recently published (2). We reported on the first-in-humans transcatheter tricuspid valve repair by using a pledgeted suture (Mitralign System, Mitralign Inc., Tewksbury, Massachusetts) (3).

prosthesis: first-in-man experience. J Am Coll Cardiol 2013;61:1929–31. 2. Campelo-Parada F, Perlman G, Philippon F, et al. First-in-man experience of a novel transcatheter repair system for treating severe tricuspid regurgitation. J Am Coll Cardiol 2015;66:2475–83. 3. Schofer J, Bijuklic K, Tiburtius C, et al. First-in-human transcatheter tricuspid valve repair in a patient with severely regurgitant tricuspid valve. J Am Coll Cardiol 2015;65:1190–5.

Our patient had no shelf to use for pledget placement, but the right atrium was large enough to steer

Bridging Anticoagulation

the guide catheter and a coaptation was sufficient to grasp the leaflets in the area of significant TR. Therefore, she was deemed a suitable candidate for

The recent comprehensive and thoughtful review by

the percutaneous mitral valve repair procedure.

Drs. Rechenmacher and Fang (1) emphasizes that the

Theoretically, this procedure can be performed from

benefit of bridging anticoagulation therapy (i.e.,

the internal jugular or femoral vein. We chose the

decreasing thromboembolic events by limiting the

femoral vein as the access site because it gives more

duration of anticoagulation interruption) must be

stability to the guide catheter and facilitates steering

carefully balanced against its risk of untoward peri-

maneuvers.

procedural bleeding.