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Canadian Journal of Cardiology

Transcatheter Interventions for Tricuspid Valve Disease: What to Do and Who to Do It On

Published:January 21, 2021DOI:https://doi.org/10.1016/j.cjca.2020.12.029

      Abstract

      Tricuspid valve disease, and particularly the management of severe tricuspid regurgitation (TR), has gained momentum in recent years. Although it is well known that this frequent condition is associated with poor clinical outcomes, these patients have been classically managed medically, leading to end-stage right ventricular heart failure. Moreover, late referral to surgery has contributed to a high rate of periprocedural complications and in-hospital surgical mortality. Thus, the development of a less invasive catheter-based therapy would be of high clinical relevance in this context. Several transcatheter tricuspid valve intervention (TTVI) devices have been developed in recent years. The particular characteristics of the tricuspid valve (large noncalcific annulus, presence of chief surrounding structures such as the conduction system or the right coronary artery) make multimodality imaging (eg, transesophageal echocardiography, computed tomography) key in the preprocedural assessment of TTVI. According to their mechanism of action and therapeutic target, TTVI includes transcatheter repair either with coaptation or annuloplasty systems, caval valve devices, and transcatheter tricuspid valve replacement. The initial TTVI experience showed that most procedures were well tolerated, with high procedural success and low in-hospital and early mortality. Also, most TTVI recipients improved their functional status and recent data suggest improved outcomes compared with medical management. However, the rate of significant residual TR after transcatheter tricuspid valve repair remains high and very scarce data exist on longer term (beyond 6-12 months) outcomes. The present review provides an overview regarding the framework of chronic TR and TTVI therapeutic options, and describes the updated current evidence in this challenging field.

      Résumé

      La valvulopathie tricuspidienne, et plus particulièrement la prise en charge d’une insuffisance tricuspidienne sévère, reçoit plus d’attention ces dernières années. Même s’il est bien connu que cette maladie fréquente est associée à une issue clinique défavorable, elle a traditionnellement été prise en charge par des médicaments et menait à une insuffisance cardiaque ventriculaire droite terminale. Par ailleurs, l’orientation tardive en chirurgie a contribué à un taux élevé de complications périopératoires et de mortalité postopératoire à l’hôpital. L’avènement d’un traitement moins invasif par cathéter aurait donc une grande pertinence clinique dans ce contexte. Plusieurs dispositifs permettant une intervention sur la valve tricuspide par voie transcathéter (TTVI) ont été conçus depuis quelques années. Les caractéristiques particulières de la valve tricuspide (grand anneau non calcifié, présence de structures avoisinantes principales telles que le système de conduction ou l'artère coronaire droite) rendent l’imagerie multimodalité (p. ex., échocardiographie transœsophagienne, tomodensitométrie) essentielle dans l’évaluation préalable à une TTVI. Selon le mode d’action et la cible thérapeutique, une TTVI comprend une réparation par voie transcathéter avec systèmes de coaptation ou d’annuloplastie, la pose d’une valve dans la veine cave et un remplacement transcathéter de la valve tricuspide. Les premières expériences de TTVI ont montré que la plupart des interventions avaient été bien tolérées, que le taux de succès avait été élevé et qu’il y avait eu peu de mortalité à l’hôpital et décès précoces. De plus, l’état fonctionnel s’est amélioré chez la majorité des patients ayant subi une TTVI, et des données récentes indiquent que les résultats seraient meilleurs qu’avec une prise en charge médicale. Toutefois, le taux d'insuffisance tricuspidienne résiduelle importante après une réparation de valve tricuspide par voie transcathéter demeure élevé et il n’existe que de très rares données sur l’issue à plus long terme (au-delà de 6 à 12 mois). La présente revue fournit un aperçu du cadre d'insuffisance tricuspidienne chronique et d’options thérapeutiques en matière de TTVI, et décrit les données probantes actualisées dans ce domaine complexe.
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