Abstract
A 67-year-old patient with history of heart transplantation was referred for symptomatic severe tricuspid regurgitation. Diagnostic workup showed chordal ruptures on the septal and anterior leaflets, most likely related to endomyocardial biopsies. Given the high surgical risk, the patient was treated percutaneously, with good results persisting at 3 months. (Level of Difficulty: Intermediate.)
Key Words: cardiac transplant, tricuspid valve, valve repair
Central Illustration
History of Presentation
A 67-year-old man presented to our heart valve unit for severe symptomatic tricuspid regurgitation (TR).
Learning Objectives
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To highlight the relatively high prevalence of TR after repetitive endomyocardial biopsies in a patient with heart transplantation.
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To introduce percutaneous tricuspid repair as a novel minimally invasive TR treatment in this setting.
Past Medical History
His past medical history was relevant for dilated cardiomyopathy, for which he underwent cardiac transplantation years later with a complicated postoperative time, after which he was discharged with normal cardiac function and without valvular disease. He had regular follow-up afterward, with repeated transjugular right ventricular biopsies. A few months following the transplantation, after a follow-up endomyocardial biopsy, transthoracic echocardiography evidenced the appearance of new severe TR (Figure 1, Video 1).
Figure 1.
Transthoracic Echocardiography Showing Severe Tricuspid Regurgitation
The patient was managed conservatively for 3 years, after which he developed worsening signs of right-side heart failure despite optimization of his antifailure treatment, including high doses of diuretics. He was therefore referred to our unit for further management for his tricuspid valve.
Investigations
Initial evaluation showed mild anemia with a hemoglobin level of 10.5 g/dL and severe renal dysfunction with an estimated glomerular filtration rate of 13 mL/min/1.73 m2. B-type natriuretic peptide level was above 5,000 ng/mL.
Echocardiographic assessment showed severe TR (IV/V) with an estimated regurgitation orifice area of 0.75 to 1 cm2 and a vena contracta of 10 mm. Chordal rupture was identified on the septal and posterior leaflets with a flail gap of 5 mm (Figure 2, Video 2). Left ventricular ejection fraction was at 55% with adequate function of mitral and aortic valves. Right ventricular function was also normal, with a tricuspid annular plane systolic excursion of 20 mm, an S-wave of 16 cm/s, and a free right ventricular wall strain of -19%, despite a slightly dilated right ventricle with an end-diastolic area of 24 cm2 and an end-systolic area 13 cm2. Fractional area change was 45%. Echocardiographic pulmonary artery systolic pressure was 60 mm Hg, and invasive pulmonary artery systolic pressure was 65 mm Hg with a right atrial V-wave of 25 mm Hg. Pulmonary vascular resistance was 2.12 WU.
Figure 2.
Transesophageal Echocardiographic Assessment of the Tricuspid Valve
Transesophageal echocardiography showing prolapses of the (A) septal and (B) posterior leaflets.
Management
Taking into consideration all of these factors, EuroScore 2 was 11.29% and TRI-SCORE was 6/12, predicting an in-hospital mortality of 22%.1 After discussion at the heart valve meeting, the risk of TR surgery was considered prohibitive, given that it was a redo surgery in a patient with pulmonary hypertension and receiving an immunosuppressive therapy. A transcatheter TR repair was decided to improve the symptoms and preserve the right ventricular function in this otherwise well-functioning transplanted heart.
The procedure was performed under general anesthesia using a TriClip device (Abbott) with 2 clips placed anteroseptally and posteroseptally (Video 3A, Video 3B, Video 3C, Video 3D, Video 3E). Postprocedural echocardiography showed a TR grade I/V, with a mean transvalvular gradient of 2 mm Hg and an systolic pulmonary artery pressure of 25 mm Hg (Figure 3, Videos 4A and 4B). Both tricuspid annular plane systolic excursion and S waves decreased slightly (18 mm and 13 mm, respectively).
Figure 3.
Final Echocardiographic Results
Two clips are attached to the anteroseptal and posteroseptal leaflets, resulting in a reduction of tricuspid regurgitation to a grade I/V. (A) End-procedural result on transesophageal echocardiography. (B, C) Transthoracic echocardiography at discharge.
Discussion
During follow-up after heart transplantation, severe TR can be encountered in up to 25% of cases. Several mechanisms can explain this high rate, including right ventricle dilation and dysfunction leading to secondary TR and repetitive endomyocardial biopsies performed for allograft rejection detection.2,3 Surgical treatment of TR in this setting carries a high risk in those patients who are under immunosuppressive treatment with a history of cardiac surgery either for cardiac transplant only or additional procedures before transplant. Percutaneous treatment of TR has recently emerged as a treatment option in patients with severe TR at high risk for cardiac surgery.4, 5, 6 Its use therefore seems attractive in those patients and, as illustrated by our clinical observation, can provide an opportunity to treat TR while avoiding a high-risk surgery in such fragile patients. The feasibility of edge-to-edge repair should be assessed as in native hearts, with estimation of leaflet mobility and length as well as measurement of gaps between the leaflets in the grasping zone. In the particular case of TR in heart transplant recipients, potential damage to the leaflets during endomyocardial biopsy should be ruled out, as should too-high prolapse or flail gap caused by subvalvular apparatus damage such as chordal rupture, because those conditions might hinder tricuspid edge-to-edge repair. Finally, the presence of edge-to-edge device may complicate future endomyocardial biopsies, and this is another issue to take into account in posttransplant patients. However, with advances in immunosuppression and donor selection strategies, acute allograft rejection has declined. The majority of rejections occur within 6 months after heart transplantation. Beyond the first year, indications for biopsies are sparse, especially in patients with tailored and stable immunosuppression. If clearly indicated (a switch in immunosuppressive strategy because of cancer or severe kidney disease), biopsies can be performed under transesophageal echocardiography control by a trained operator. The use of “virtual biopsies” based on donor-derived cell-free DNA detection in the blood of heart transplant recipients should decrease the need for invasive endomyocardial biopsies in the future.
Conclusions
Percutaneous repair is a promising solution for patients presenting with TR after heart transplant, allowing a minimally invasive treatment in this high-risk population. The durability and reproducibility of the results need to be documented in large case series to confirm the yield of this strategy.
Funding Support and Author Disclosures
Dr Martin has received consultant fees and research grant from Alliance BMS-Pfizer and consultant fees from Abbott, Bayer, and Novartis outside the submitted work. Dr Karam has received consultant fees from Abbott Vascular, Edwards Lifesciences, and Medtronic outside the submitted work. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
Footnotes
The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the Author Center.
Appendix
For supplemental videos, please see the online version of this paper.
Appendix
Transthoracic Echocardiography Showing Severe TR
Transesophageal Echocardiography Showing a Prolapse of the Septal Leaflet
Per-Procedural Transesophageal Guidance of the Tricuspid Edge-to-Edge Procedure. (A) Deep transesophageal X-plan view showing the alignment of the clip anteroseptally. (B) Deep transesophageal X-plan view showing the grasping of the anterior and septal leaflets. (C) Deep transesophageal X-plan view with color Doppler showing severe posteroseptal residual TR caused by the posterior leaflet prolapse. (D) Deep transesophageal X-plan view showing the grasping of the posterior and septal leaflets. (E) Deep transesophageal view with Doppler color showing the 2 clips attached to the tricuspid valve with minimal residual TR
Per-Procedural Transesophageal Guidance of the Tricuspid Edge-to-Edge Procedure. (A) Deep transesophageal X-plan view showing the alignment of the clip anteroseptally. (B) Deep transesophageal X-plan view showing the grasping of the anterior and septal leaflets. (C) Deep transesophageal X-plan view with color Doppler showing severe posteroseptal residual TR caused by the posterior leaflet prolapse. (D) Deep transesophageal X-plan view showing the grasping of the posterior and septal leaflets. (E) Deep transesophageal view with Doppler color showing the 2 clips attached to the tricuspid valve with minimal residual TR 4
Per-Procedural Transesophageal Guidance of the Tricuspid Edge-to-Edge Procedure. (A) Deep transesophageal X-plan view showing the alignment of the clip anteroseptally. (B) Deep transesophageal X-plan view showing the grasping of the anterior and septal leaflets. (C) Deep transesophageal X-plan view with color Doppler showing severe posteroseptal residual TR caused by the posterior leaflet prolapse. (D) Deep transesophageal X-plan view showing the grasping of the posterior and septal leaflets. (E) Deep transesophageal view with Doppler color showing the 2 clips attached to the tricuspid valve with minimal residual TR 5
Per-Procedural Transesophageal Guidance of the Tricuspid Edge-to-Edge Procedure. (A) Deep transesophageal X-plan view showing the alignment of the clip anteroseptally. (B) Deep transesophageal X-plan view showing the grasping of the anterior and septal leaflets. (C) Deep transesophageal X-plan view with color Doppler showing severe posteroseptal residual TR caused by the posterior leaflet prolapse. (D) Deep transesophageal X-plan view showing the grasping of the posterior and septal leaflets. (E) Deep transesophageal view with Doppler color showing the 2 clips attached to the tricuspid valve with minimal residual TR 6
Per-Procedural Transesophageal Guidance of the Tricuspid Edge-to-Edge Procedure. (A) Deep transesophageal X-plan view showing the alignment of the clip anteroseptally. (B) Deep transesophageal X-plan view showing the grasping of the anterior and septal leaflets. (C) Deep transesophageal X-plan view with color Doppler showing severe posteroseptal residual TR caused by the posterior leaflet prolapse. (D) Deep transesophageal X-plan view showing the grasping of the posterior and septal leaflets. (E) Deep transesophageal view with Doppler color showing the 2 clips attached to the tricuspid valve with minimal residual TR 7
Final Echocardiographic Results. Two clips are attached to the anteroseptal and posteroseptal leaflets, resulting in a reduction of TR to grade I/V. (A) Apical 4-chamber view showing minimal residual TR. (B) Modified parasternal view showing the 2 clips on the tricuspid valve with minimal residual TR. 8
Final Echocardiographic Results. Two clips are attached to the anteroseptal and posteroseptal leaflets, resulting in a reduction of TR to grade I/V. (A) Apical 4-chamber view showing minimal residual TR. (B) Modified parasternal view showing the 2 clips on the tricuspid valve with minimal residual TR. 9
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Transthoracic Echocardiography Showing Severe TR
Transesophageal Echocardiography Showing a Prolapse of the Septal Leaflet
Per-Procedural Transesophageal Guidance of the Tricuspid Edge-to-Edge Procedure. (A) Deep transesophageal X-plan view showing the alignment of the clip anteroseptally. (B) Deep transesophageal X-plan view showing the grasping of the anterior and septal leaflets. (C) Deep transesophageal X-plan view with color Doppler showing severe posteroseptal residual TR caused by the posterior leaflet prolapse. (D) Deep transesophageal X-plan view showing the grasping of the posterior and septal leaflets. (E) Deep transesophageal view with Doppler color showing the 2 clips attached to the tricuspid valve with minimal residual TR
Per-Procedural Transesophageal Guidance of the Tricuspid Edge-to-Edge Procedure. (A) Deep transesophageal X-plan view showing the alignment of the clip anteroseptally. (B) Deep transesophageal X-plan view showing the grasping of the anterior and septal leaflets. (C) Deep transesophageal X-plan view with color Doppler showing severe posteroseptal residual TR caused by the posterior leaflet prolapse. (D) Deep transesophageal X-plan view showing the grasping of the posterior and septal leaflets. (E) Deep transesophageal view with Doppler color showing the 2 clips attached to the tricuspid valve with minimal residual TR 4
Per-Procedural Transesophageal Guidance of the Tricuspid Edge-to-Edge Procedure. (A) Deep transesophageal X-plan view showing the alignment of the clip anteroseptally. (B) Deep transesophageal X-plan view showing the grasping of the anterior and septal leaflets. (C) Deep transesophageal X-plan view with color Doppler showing severe posteroseptal residual TR caused by the posterior leaflet prolapse. (D) Deep transesophageal X-plan view showing the grasping of the posterior and septal leaflets. (E) Deep transesophageal view with Doppler color showing the 2 clips attached to the tricuspid valve with minimal residual TR 5
Per-Procedural Transesophageal Guidance of the Tricuspid Edge-to-Edge Procedure. (A) Deep transesophageal X-plan view showing the alignment of the clip anteroseptally. (B) Deep transesophageal X-plan view showing the grasping of the anterior and septal leaflets. (C) Deep transesophageal X-plan view with color Doppler showing severe posteroseptal residual TR caused by the posterior leaflet prolapse. (D) Deep transesophageal X-plan view showing the grasping of the posterior and septal leaflets. (E) Deep transesophageal view with Doppler color showing the 2 clips attached to the tricuspid valve with minimal residual TR 6
Per-Procedural Transesophageal Guidance of the Tricuspid Edge-to-Edge Procedure. (A) Deep transesophageal X-plan view showing the alignment of the clip anteroseptally. (B) Deep transesophageal X-plan view showing the grasping of the anterior and septal leaflets. (C) Deep transesophageal X-plan view with color Doppler showing severe posteroseptal residual TR caused by the posterior leaflet prolapse. (D) Deep transesophageal X-plan view showing the grasping of the posterior and septal leaflets. (E) Deep transesophageal view with Doppler color showing the 2 clips attached to the tricuspid valve with minimal residual TR 7
Final Echocardiographic Results. Two clips are attached to the anteroseptal and posteroseptal leaflets, resulting in a reduction of TR to grade I/V. (A) Apical 4-chamber view showing minimal residual TR. (B) Modified parasternal view showing the 2 clips on the tricuspid valve with minimal residual TR. 8
Final Echocardiographic Results. Two clips are attached to the anteroseptal and posteroseptal leaflets, resulting in a reduction of TR to grade I/V. (A) Apical 4-chamber view showing minimal residual TR. (B) Modified parasternal view showing the 2 clips on the tricuspid valve with minimal residual TR. 9