38 Transcatheter tricuspid valve edge-to-edge repair in patient with severe tricuspid regurgitation and previous mitraclip treatment: when four orifices are better than two
Abstract An 82 years old woman was admitted to our Division for worsening dyspnoea. Her past medical history showed: arterial hypertension, chronic atrial fibrillation on oral anticoagulation, a non-critical single-vessel coronary artery disease, previous mitral transcatheter edge-to-edge repair through 2 Mitraclip NTR. After an initial improvement in clinical symptoms following Mitraclip implantation, the patient was admitted several times for acute decompensated heart failure. Haematological exams at admission were normal, exception of NTproBNP (1909 pg/mL). The ECG documented atrial fibrillation with normal ventricular rate. Transthoracic echocardiography demonstrated mid-range heart failure (EF 45–50%) with D-shape morphology of the left ventricle. Colour-doppler analysis shows presence of Mitraclip devices in place with mild residual insufficiency, dilation of the right side, torrential tricuspid regurgitation (tTR) with estimated pulmonary arterial pressure of 45 mmHg. Preprocedural transesophageal echocardiography confirmed these findings showing dilation of the tricuspid annulus with two large regurgitating jets. After positioning Amplatzer Superstiff guide in superior vena cava through guide catheter TSGC0202, a Triclip XT was placed in commissural region between anterior and septal leaflets. A two-grade reduction in tricuspid regurgitation (TR) grade from torrential (5+) to moderate (3+) was achieved without significant transvalvular gradient. The patient was successful discharged after 2 days, asymptomatic and in good clinical conditions. A great reduction in NTproBNP values at discharge was observed (1612 pg/mL). We report a case of successful tricuspid transcatheter repair in patient with chronic decompensated heart failure and previous Mitraclip treatment. The clinical impact of TR reduction is probably due to a positive right ventricular (RV) remodelling, with a reduction in RV size. RV dysfunction and its implications (liver, renal, and haemostatic consequences) are definitely a matter of concern for fragile patients with TR. In fact, many patients with severe TR have a reduced RV function. The reduction in volume and pressure overload of the right heart side, the progressive anatomic and functional reverse of the RV disfunction, may lead to a significant clinical benefit and to a lower hospitalizations rates also through to an important improvement of the left ventricular function as a consequence of the reduction in pressure overload.