PERCUTANEOUS CORRECTION OF "BADLY ACCOMPANIED" MASSIVE TRICUSPID REGURGITATION

Abstract

Abstract Background Tricuspid regurgitation (TR) is a common valvular pathology that impairs quality of life and survival. Tricuspid transcatheter edge–to–edge repair (t–TEER) has shown promising potential in the TR treatment. There remains several uncertainties such as timing of intervention in relation to clinical status, RV function, pulmonary artery pressure and many comorbidities that are often overlooked. Case Summary A 80–year–old man with dilated cardiomyopathy, persistent atrial fibrillation and biventricular defibrillator (ICD), was admitted to our centre for congestive heart failure (CHF). Echocardiography showed massive TR, severe right heart dilatation, increased systolic pulmonary artery pressure, severely dilated inferior vena cava (IVC) and hepatic veins with systolic flow reversal. We also found an uncommonly high blood flow coming to the right atrium from the IVC, due to an anomalous vascular communication between an intrahepatic portal branch and a hepatic vein, a so–called intrahepatic portosystemic venous shunt (IPSVS). Although these relatively rare shunts are usually not treated unless symptomatic, after a collective careful evaluation, we decided to proceed to the embolization of the IPSVS with a vascular plug, to make the t–TEER less challenging, safer and more durable. In better general conditions, after 2 months, the patient underwent the transcatheter tricuspid procedure with a single XTW TriClip™ (Abbott). At 3 months follow–up, the patient showed noticeable improvements in QoL, CHF signs and symptoms, echocardiographic parameters and exercise capacity. Discussion Appropriate timing of t–TEER is crucial not only to avoid irreversible RV damage and organ failure, but also to increase the success rate of the procedures. In this case we observed that the IPSVS treatment contributed significatively to improve the patient’s clinical status and to reduce the right heart volume overload before attempting the t–TEER. This combined approach facilitated the technical success of tricuspid procedure, that was itself challenging due to the ICD leads in the right chambers. Conclusion Patients’ selection and timing of percutaneous TR treatment are not clearly defined. This case shows that a winning strategy to approach challenging TR is to solve, before the tricuspid treatment, all the potentially treatable comorbidities that could negatively interfere with the technical success of the procedure itself and with the durability of TR reduction.