Transcatheter bicaval valve implantation as interventional treatment in a non-surgical patient with severe tricuspid regurgitation

Abstract

Introduction: Despite recent advances in interventional treatment of heart valve disease, no transcatheter approach is yet established for severe tricuspid regurgitation (TR). Valve implantation into the inferior vena cava (IVC) has been suggested and previously reported in human patients as interventional approach to TR. However, single valve implantation into the IVC has been shown to reduce venous regurgitation only to the lower body, thus only partially resolving the hemodynamic sequelae of TR. Case report description: Herein, we report the first human case of bi-caval valve implantation in the superior (SVC) and inferior vena cava in a 83-year-old non-surgical patient with severe symptomatic TR. Two self-expanding, pericardial tissue valves were custom-made and adopted to the anatomy of the anticipated valve landing zones in the SVC and IVC. Device implantation was performed under fluoroscopic and echocardiographic guidance through the right femoral vein. After loading into a 27F-catheter, the first device was aligned to the level of the cavo-atrial junction of the SVC and successively deployed. Thereafter, the second valve was aligned to the cavo-atrial junction of the IVC just above the hepatic vein inflow and deployed with the valve protruding into the right atrium (RA). Valve implantation and fixation was technically feasible. Immediately after deployment, excellent function of both devices was confirmed by angiography and echocardiography. The procedure resulted in a marked reduction of the ventricular wave (v-wave) in the SVC from 30 to 24mmHg and in the IVC from 28 to 16mmHg, respectively. The patient experienced an uneventful recovery without recurrence of right heart failure during early follow-up. Functional capacity improved with an increase in 6-minute walk distance from 20 to 120m. Sequential echo exams over a follow-up period of 6 weeks confirmed continuous device function without paravalvular leakage or remaining venous regurgitation. She was discharged home from hospital after 15 days and continuous on ambulatory follow-up. Conclusions and clinical implication: Transcatheter valve implantation into the SVC and IVC is technically feasible in human patients and results in immediate hemodynamic improvement with abolition of central venous regurgitation. Further confirmatory experience with longer follow-up is required to evaluate the short- and long-term clinical benefit as well as potential deleterious effects of the procedure. This technique may potentially expand the therapeutic options for patients with severe TR.