Do Not Let Them Fall-ot

Corresponding Author

Supported by scientific evidence, transcatheter therapies have significantly evolved and spread over the past few years, becoming in some cases the first-choice treatment for some heart valve diseases. In particular, tricuspid regurgitation (TR) has been the last to be investigated although a renewed interest has grown around tricuspid valve disease in the last decade.¹ After the experience with mitral valve disease, transcatheter edge-to-edge repair (TEER) has rapidly become the most used procedure to treat TR. Current European guidelines indicate tricuspid TEER (T-TEER) to improve quality of life and RV remodeling in high-risk patients with symptomatic severe TR despite optimal medical therapy, in the absence of severe RV dysfunction or pre-capillary pulmonary hypertension (Class 2a, Level of Evidence: A).² Current trials demonstrated benefits of T-TEER over medical therapy, especially in terms of symptoms and quality of life.^3,4 In clinical practice, T-TEER is often selected in those patients deemed not suitable for surgery for the high operative risk. However,the correct timing of intervention is still an open issue. Dedicated risk scores have been proposed to define those patients who may benefit most from T-TEER.^5,6

In the case presented by Azizi et al,⁷ a patient with repaired tetralogy of Fallot (rTOF) underwent TR treatment with TriClip (Abbott). The case was successful, with 2 clips implanted, significant TR improvement, and reverse remodeling, as already demonstrated in the TriValve registry.⁸ Currently, patients with rTOF represent a wide population of patients at risk for right heart failure, with significant TR occurring in up to one-third of cases. Reinterventions are common after rTOF, reaching 25% after 7 years from the index procedure, and in some cases, 2 or 3 reinterventions might be needed.⁹

The present case suggests 2 important considerations: first, in a lifetime perspective, the role of percutaneous therapy might become increasingly important. Indeed, redo surgery brings a high risk for reintervention, especially for second or third reoperations, and in this case, transcatheter interventions might become a valid alternative to surgery, as in the case presented. Second, although the number of patients undergoing transcatheter treatments is increasing in all fields of valvular disease, patients with adult congenital heart disease may represent a group of patients who will benefit from such therapies in a lifetime perspective.¹⁰ For instance, transcatheter aortic valve replacement has been described both in isolated lesions (bicuspid aortic valve) and in cases of complex syndromes such as Shone syndrome.¹¹ Similarly, mitral TEER has been described in the setting of hypoplastic left heart syndrome with Fontan circulation or in a complete atrioventricular canal.¹² It is, therefore, likely that percutaneous intervention will play an important role in the near future, also in the management of adult congenital heart disease. Moreover, in consideration of the complexity of such procedures, the integration of augmented reality, artificial intelligence, and robotics in the near future may further boost structural heart valve interventions.^13,14

Funding Support and Author Disclosures

Dr Russo has received a fellowship training grant from EAPCI, sponsored by Edwards Lifesciences, and fee honoraria from Abiomed. Dr Taramasso has received consultancy fees from Abbott Vascular, Edwards Lifesciences, 4Tech, Boston Scientific, CoreMedic, Mitraltech, and SwissVortex, outside the submitted work.