Transcatheter Tricuspid Valve Replacement and CLEFT After Tricuspid TEER

Severe tricuspid regurgitation (TR) is associated with excess mortality and symptoms of heart failure. Tricuspid transcatheter edge-to-edge repair (T-TEER) alleviates symptoms, but not all T-TEER achieve optimal results. Transcatheter tricuspid valve replacement (TTVR) after T-TEER is possible, but short-term outcomes are not well known, and some patients require advanced electrosurgical techniques to facilitate TTVR.

The aim of this paper is to describe techniques and outcomes among patients who underwent TTVR after T-TEER.

The authors describe initial experience and lessons learned for TTVR after T-TEER, including CLEFT (clip liberalization to facilitate TTVR), and an algorithm to guide TTVR procedural planning. The authors also report the outcomes of a series of TTVR procedures after T-TEER, with or without CLEFT. The primary outcome was procedural technical success. Secondary outcomes included 30-day mortality, TR severity, and NYHA functional class.

A total of 16 patients with severe, symptomatic TR after T-TEER were treated with TTVR using the EVOQUE valve. The median age was 75 years (Q1-Q3: 67-85 years), and 68.8% patients (11 of 16) were women. Median Society of Thoracic Surgeons Predicted Risk of Mortality was 8.3% (Q1-Q3: 6.9%-12.4%). Thirteen patients (81.3%) were in NYHA functional class III or IV. Eight patients underwent leaflet modification immediately prior to TTVR. The procedural technical success rate was 93.7% (15 of 16; 95% CI: 69.8%-99.8%). Survival to 30 days was 93.7% (15 of 16). The proportion of patients in NYHA functional class I or II improved to 86.7% (13 of 16; P < 0.001 compared with baseline), and TR severity was reduced (93.3% with no or mild TR; P < 0.001) at 30 days.

The authors present the largest series of TTVR after T-TEER with electrosurgical leaflet modification in a subset of patients. At 30 days, TR severity was markedly reduced, and substantial symptom alleviation occurred.