Tricuspid Position Research Articles

Tricuspid Structural Valve Deterioration Treated with a Transcatheter Valve-in-Valve Implantation: A Single-Center Prospective Registry.

The valve-in-valve (ViV) technique is an emerging alternative for the treatment of bioprosthetic structural valve deterioration (SVD) in the tricuspid position. We report on the outcomes of patients treated by a transcatheter tricuspid valve-in-valve (TT-ViV) implantation for symptomatic SVD in the tricuspid position during the years 2010–2019 at our center. Three main outcomes were examined during the follow-up period: TT-ViV hemodynamic data per echocardiography, mortality and NYHA functional class. Our cohort consisted of 12 patients with a mean age 65.4 ± 11.9 years, 83.3% male. The mean time from initial valve intervention to TT-ViV was 17.4 ± 8.7 years. The indications for TT-ViV were varied (41.7% for predominant regurgitation, 33.3% for predominant stenosis and 25.0% with a mixed pathology). All patients were treated with a balloon-expandable device. The mean follow-up was 3.4 ± 1.3 years. Tricuspid regurgitation was ≥ moderate in 57.2% of patients prior to the procedure and this decreased to 0% following the procedure. The mean transtricuspid valve gradients mildly decreased from the mean pre-procedural values of 9.0 mmHg to 7.0 mmHg at one month following the procedure (p = 0.36). Mortality at one year was 8.0% (95% CI 0–23). At the baseline, 4 patients (33.3%) were in NYHA functional class III/IV; this was reduced to 2 patients (18.2%) at the one year follow-up and both were in NYHA III. The TT-ViV procedure offered a safe, feasible and less invasive treatment option for patients with SVD in our detailed cohort.

Late Balloon Valvuloplasty for Transcatheter Heart Valve Dysfunction

BackgroundTranscatheter heart valve (THV) dysfunction with an elevated gradient or paravalvular leak (PVL) may be documented late after THV implantation. Medical management, paravalvular plugs, redo THV replacement, or surgical valve replacement may be considered. However, late balloon dilatation is rarely utilized because of concerns about safety or lack of efficacy. ObjectivesWe aimed to evaluate the safety and efficacy of late dilatation in the management of THV dysfunction. MethodsAll patients who underwent late dilatation for symptomatic THV dysfunction at 2 institutions between 2016 and 2021 were identified. Baseline, procedural characteristics, and clinical and echocardiographic outcomes were documented. THV frame expansion was assessed by multislice computed tomography before and after late dilatation. ResultsLate dilatation was performed in 30 patients a median of 4.6 months (IQR: 2.3-11.0 months) after THV implantation in the aortic (n = 25; 83.3%), mitral (n = 2; 6.7%), tricuspid (n = 2; 6.7%) and pulmonary (n = 1; 3.3%) position. THV underexpansion was documented at baseline, and frame expansion substantially improved after late dilatation. The mean transvalvular gradient fell in all patients. For aortic THVs specifically, mean transaortic gradient fell from 25.4 ± 13.9 mm Hg to 10.8 ± 4.1 mm Hg; P < 0.001. PVL was reduced to ≤mild in all 11 patients with a previous >mild PVL. Embolic events, stroke, annular injury, and bioprosthetic leaflet injury were not observed. Symptomatic benefit was durable at 19.6 months (IQR: 14.8-36.1 months) follow-up. ConclusionsBalloon dilatation late after THV implantation appears feasible and safe in appropriately selected patients and may result in THV frame expansion resulting in improvements in hemodynamic performance and PVL.

Implantation of a transcatheter valve in the tricuspid position in a patient with Ebstein's anomaly using the valve-in-valve technique: case report

The article presents the first experience of implantation of the Russian transcatheter prosthesis "MedLab-KT" in the tricuspid position. The procedure was performed on a high-risk patient with a history of five open surgical interventions for Ebstein's anomaly with developed dysfunction of a previously implanted biological prosthesis. Implantation was carried out by transatrial valve-in-valve technique to the position of a biological prosthesis. The postoperative period was uneventful. The presented clinical case showed to the effectiveness and safety of the transcatheter PTFE prosthesis "MedLab-KT" during valve-in-valve implantation in case of dysfunction of the biological prosthesis in the tricuspid position.Received 10 October 2021. Accepted 29 October 2021.Funding: The research was carried out within the state assignment of Ministry of Health of Russian Federation (No. 121032300337-5).Conflict of interest: Authors declare no conflict of interest.Contribution of the authors Literature review: I.I. Tihonova, O.Yu. Malakhova Drafting the article: A.V. Karadzha Critical revision of the article: A.V. Bogachev-Prokophiev, A.V. Voitov, R.M. Sharifulin Surgical treatment: A.V. Voitov, R.M. Sharifulin Final approval of the version to be published: A.V. Karadzha, A.V. Voitov, A.V. Bogachev-Prokophiev, R.M. Sharifulin, I.I. Tihonova, O.Yu. Malakhova

Two case reports of transcatheter valve-in-valve implantation of Sapien 3 and MyVal in degenerated biological tricuspid prosthesis valves

BackgroundPatients with severe tricuspid valve stenosis or dysfunction following degeneration of biological valve prosthesis in tricuspid position are complex, have substantial comorbidity, and very high surgical risk.Case summaryWe report two cases with transcatheter tricuspid valve-in-valve implantation in patients with degenerated tricuspid bioprosthesis with transfemoral and transjugular access with Sapien 3 valve and MyVal, respectively.DiscussionIn patients with high surgical risk, transcatheter tricuspid valve implantation is a good alternative. Careful consideration of optimal access site, device size, and delivery system is paramount. This case report demonstrates technically feasible and safe transcatheter valve-in-valve implantantion in tricuspid position and highlights the importance of meticulous procedure planning.

Defibrillation lead damage in a patient with MitraClip XTR device in tricuspid position.

Defibrillation lead damage in a patient with MitraClip XTR device in tricuspid position.

Transcatheter Valve-in-Valve Procedures for Bioprosthetic Valve Dysfunction in Patients With Rheumatic vs. Non-Rheumatic Valvular Heart Disease.

Background: Bioprosthetic heart valve has limited durability and lower long-term performance especially in rheumatic heart disease (RHD) patients that are often subject to multiple redo operations. Minimally invasive procedures, such as transcatheter valve-in-valve (ViV) implantation, may offer an attractive alternative, although data is lacking. The aim of this study was to evaluate the baseline characteristics and clinical outcomes in rheumatic vs. non-rheumatic patients undergoing ViV procedures for severe bioprosthetic valve dysfunction.Methods: Single center, prospective study, including consecutive patients undergoing transcatheter ViV implantation in aortic, mitral and tricuspid position, from May 2015 to September 2020. RHD was defined according to clinical history, previous echocardiographic and surgical findings.Results: Among 106 patients included, 69 had rheumatic etiology and 37 were non-rheumatic. Rheumatic patients had higher incidence of female sex (73.9 vs. 43.2%, respectively; p = 0.004), atrial fibrillation (82.6 vs. 45.9%, respectively; p < 0.001), and 2 or more prior surgeries (68.1 vs. 32.4%, respectively; p = 0.001). Although, device success was similar between groups (75.4 vs. 89.2% in rheumatic vs. non-rheumatic, respectively; p = 0.148), there was a trend toward higher 30-day mortality rates in the rheumatic patients (21.7 vs. 5.4%, respectively; p = 0.057). Still, at median follow-up of 20.7 [5.1–30.4] months, cumulative mortality was similar between both groups (p = 0.779).Conclusion: Transcatheter ViV implantation is an acceptable alternative to redo operations in the treatment of patients with RHD and severe bioprosthetic valve dysfunction. Despite similar device success rates, rheumatic patients present higher 30-day mortality rates with good mid-term clinical outcomes. Future studies with a larger number of patients and follow-up are still warranted, to firmly conclude on the role transcatheter ViV procedures in the RHD population.

Pacing leads in transcatheter tricuspid valve

Abstract Funding Acknowledgements Type of funding sources: None. Background Transcatheter therapy of bioprothesis in tricuspid position and the native tricuspid valve are a growing field in interventional cardiology. Yet, the presence of pacing leads can demand a different approach. We performed a systemic review of this topic to understand the risks and the potential impact on the pacing leads. Objective Review the evidence regarding the efficacy and safety of pacing leads with the transcatheter tricuspid valve implantation. Methods A systemic research on MEDLINE and PUBMED with two the following terms "transvenous pacing", "transcatheter valve", "transcatheter tricuspid", "transvalvular leads", "tricuspid valve-in-valve" and "transvalvular pacemaker". 120 results were identified. However, just 5 papers were selected since are the only ones that described the implantation of a transcatheter tricuspid valve in patients with pacing leads and had some follow up, yet one of the papers lacks data and was excluded. The majority of papers reported the success of the procedure yet without a follow-up or the potentials complications on the pacing leads. Results Four studies were selected, including a total of 33 patients. The studies were performed with different techniques and procedures, as well as the reports regarding the echocardiogram and pacing data before the procedure and during the follow-up. Mean age 59.51 years old, 78.78% were female, 72.72% had NYHA class ≥ III, 21.21% was hospitalized in the previous 6 months, 21.21% had acute or chronic renal insufficiency, 18.18% had cirrhosis or liver disease, 51.52% had other prosthetic valves and 12.12 had history of endocarditis. Acquired etiology for tricuspid valve disease in 63.64%, atrial fibrillation in 60.60%, 78.79% had a tricuspid bioprosthetic valve, one patient had a catheter valve and the rest had a ring with or without homograft valve. 60.60% had moderate or severe tricuspid regurgitation and 15.15% had mixed tricuspid regurgitation and stenosis, with a mean tricuspid valve gradient of 7.22 mmHg. SAPIEN transcatheter valve was used in 78.79% and Melody valve in the rest. The transcatheter tricuspid implantation was a success in 32 patients, without any interference in the pacing leads. Of them, the follow-up period was diverse and heterogeneous with a mean of 13.51 months, a mean tricuspid valve gradient of 5.00 mmHg, and a register of 3 death without any relationship with the transcatheter valve or pacing complications. Was reported three complications during the follow-up regarding the pacing leads, two patients had a marked increase in the right ventricle leads impedance and stimulation threshold and one patient developed a right ventricle lead fracture. Conclusions 9.28% of the patients submitted to transcatheter tricuspid valve had pacing lead complications. Considering the small sample, further investigation regarding the impact of this procedure in the pacing leads is required for a clear assessment.

Gradient changes in bioprosthetic valve thrombosis: duration of anticoagulation and strategies to improve detection

ObjectiveBioprosthetic valve thrombosis (BPVT) is increasingly recognised as a major cause of prosthetic dysfunction in the first years postimplantation. How early abnormal gradients can be detected prior to diagnosis and...

Tricuspid Versus Mitral Performance of Cylindrical Porcine Small Intestinal Submucosa Valves

Objective: Treatment options are extremely limited for children and older patients who are contra-indicated for receiving mechanical or bioprosthetic valves. The purpose of this study is to determine whether cylindrical porcine small intestinal submucosa (PSIS) bio-scaffold valves can facilitate robust valvular function in the tricuspid location. Methods: A 26-mm PSIS cylindrical valve (CorMatrix Cardiovascular) was sutured to a custom, 3D printed valve holder along two (150°) or three (120°) posts on the distal end. The annulus ring was sealed with a 3D printed cap. Hydrodynamic testing of the valves mounted in mitral and tricuspid positions were performed using a pulse duplicator system (Vivitro Labs) using 0.9% saline solution. A flow probe was affixed between atrium and ventricular chambers, and pressure transducers were inserted in the atrial, ventricular, and aortic locations. Tests utilized heart rate of 70 BPM, input S35 waveform comprising of a 35% systolic-65% diastolic configuration (Vivitest, Vivitro Labs), with a stroke volume of 50 mL for tricuspid (Noordegraaf 2019) and 71.4 mL for mitral conditions respectively. Results: Valve performance results in the tricuspid position showed a root mean square volumetric flow rate (QRMS) of 135 mL/s, a transvalvular pressure gradient (ΔP) of 3.97 mmHg, an effective orifice area (EOA) of 1.30 cm2, and a regurgitation factor (RF) of 7.70%. In the mitral position, the results showed a QRMS of 180 mL/s, a ΔP of 8.27 mmHg, an EOA of 1.08 cm2, and an RF of 8.34%. Conclusions: Preliminary data of cylindrical PSIS valves in both tricuspid and mitral positions show clinically acceptable hydrodynamics metrics of valve performance. Additional testing will help to establish statistical significances or lack thereof between the two valve groups.

Outcomes of surgical treatment for carcinoid heart disease: A systematic review and meta-analysis

BackgroundCarcinoid heart disease (CaHD) develops from vasoactive substances released by neuroendocrine tumors, which can cause significant patient morbidity and mortality without surgical intervention. We performed a systematic review and meta-analysis to elucidate granular perioperative details and long-term outcomes in these patients. MethodsElectronic search of Ovid, Scopus, Cumulative Index of Nursing and Allied Health Literature, and Cochrane Controlled Trials Register was performed to examine surgical treatment of carcinoid disease. Nine articles comprising 416 patients were selected. Study-level data were extracted and pooled for meta-analysis. ResultsMean patient age was 63 years (95% confidence interval, 57–70) with 53% (95% confidence interval, 46–61) of patients being male. In addition, 75% (95% confidence interval, 54–96) of neuroendocrine tumors originated from the small bowel or colon and 98% (95% confidence interval, 93–100) had liver metastases. Right heart failure was present in 48% (95% confidence interval, 14–81). Moderate or severe regurgitation was present in 97% (95% confidence interval, 95–99) of tricuspid and 72% (95% confidence interval, 58–83) of pulmonary valves. In addition, 99% (95% confidence interval, 98–100) of tricuspid and 59% (95% confidence interval, 38–79) of pulmonary valves were replaced. Bioprosthetic valves were used in 80% (95% confidence interval, 68–93) of tricuspid positions. Mean hospital duration of stay was 16 days (95% confidence interval, 7–25). Thirty-day mortality was 9% (95% confidence interval, 6–12). Mean follow-up was 25 months (95% confidence interval, 11–39). Median survival was 3 years (95% confidence interval, 2.5–3.5). ConclusionFor patients >18 years of age, surgical treatment of carcinoid heart disease can be performed with a reasonable safety profile. However, overall survival appears to have ongoing effects of the primary disease.

Selección de lo mejor del año 2020 en la evaluación y tratamiento de la insuficiencia tricuspídea

Significant tricuspid regurgitation is a prevalent valvular disease with a high morbidity and mortality rate. Current guidelines do not define the precise moment in which these patients should be referred to surgery. Therefore, cardiac surgery is performed late and in the final stage of the disease. In recent years, percutaneous treatment has emerged as a great alternative to surgery in selected candidates with high surgical risk, with the MitraClip device in the tricuspid position being the most widely used. This paper addresses the main prognostic determinants of these patients, their follow-up, the indications for treatment, and the therapeutic options. Also, it establishes how the selection of candidates for a non-invasive percutaneous option should be performed, as well as the most appropriate device.

Case report: Transcatheter valve repair with Cardioband: a new treatment option for secondary tricuspid regurgitation in cardiac transplant patients.

BackgroundTricuspid regurgitation (TR) is the most frequent valvular complication after cardiac transplantation. As in native hearts, the role of surgical therapy particularly in secondary TR is unclear due to high procedural risk and unsatisfying results. Currently, percutaneous techniques are under development for TR repair with less procedural risk and promising preliminary results.Case summaryWe present a 67-year-old man who underwent heart transplantation (biatrial anastomosis) because of ischaemic heart disease 15 years ago and aortic valve replacement in 2010. Because of progressive severe dyspnoea (New York Heart Association Class III) in 2018 and signs of right heart failure with ascites he underwent transthoracic echocardiography which showed normal graft function, but massive TR of functional aetiology. The heart team decision was an interventional approach using the Cardioband System (Edwards Lifesciences) to treat TR based on the high risk associated with a third cardiac surgery and impaired right ventricular function. The procedure was performed in general anaesthesia with transoesophageal echocardiography and fluoroscopic guidance. Tricuspid regurgitation improved from massive to mild with a mean pressure gradient of 2.9 mmHg.DiscussionThis is the first case report of Cardioband implantation in tricuspid position in a heart transplant patient with the good technical and clinical result, suggesting that this technique might offer a treatment option to highly selected post-transplant patients with secondary severe TR and high surgical risk.

Which is the best prosthesis in an isolated or combined tricuspid valve replacement?

The debate concerning the optimal choice of tricuspid position continues. We compared the long-term results of mechanical and biological prostheses in patients who underwent isolated or combined tricuspid valve replacement, at 2 major cardiac surgical centres in central China. From January 1999 to December 2018, 338 patients underwent tricuspid valve replacement. Patients were divided into an isolated group or a combined group according to whether their surgery was combined with a left heart valve surgery. Mechanical tricuspid valve replacement was performed in 142 patients (isolated group: 41 vs combined group: 101), and 196 patients underwent bioprosthetic tricuspid valve replacement (isolated group: 145 vs combined group: 51). Operative results, long-term survival and tricuspid valve-related events were compared. Early mortality in the combined group was higher (n = 6, 4%) than that in the isolated group (n = 3, 2%), but no significant difference was observed between the mechanical and biological subgroups. In the isolated group, there was a higher event-free rate in the biological subgroup than in the mechanical subgroup (P = 0.042) and a similar result was also observed for patients without Ebstein's anomaly (P = 0.039). In the combined group, no significant difference was observed (P = 0.98). Survival rates were similar between the mechanical and biological subgroups in both the isolated (P = 0.54) and combined (P = 0.81) groups. Mechanical valves in isolated tricuspid valve replacement were more prone to valve thrombosis and bleeding. Every decision regarding tricuspid valve prostheses should be individualized, but biological prostheses may be an optimal choice for patients, especially for patients without Ebstein's anomaly, in isolated tricuspid valve replacement.

Atrialized right ventricular chamber as a source of ventricular tachycardia in Ebstein's anomaly. Analysis of two successful catheter ablation cases

Ventricular tachycardia in Ebstein's anomaly patients is rare and increases the risk of sudden death up to 6 times. We present two cases of Ebstein's anomaly, the first of them with a history of Glenn surgery and biological prosthesis at tricuspid position and the second case without surgical repair. Both admitted to the emergency room due to ventricular tachycardia poorly tolerated. Detailed substrate characterization and pace mapping showed fragmented signals in the area of atrialized right ventricle and correlated were pace mapping reproduced morphology identical to the clinical VT, ablation at this sites were successful without recurrence during follow-up.

A radial force-independent bioprosthesis for transcatheter tricuspid valve implantation in a preclinical model

BackgroundInterventional treatments of tricuspid regurgitation have been emerging as minimally invasive alternatives. Among those reported transcatheter tricuspid devices, the radial force between the device and native tricuspid annulus is the common principle to be employed for device immobilization. However, this immobilization mechanism may potentially lead to adverse consequences. We developed a radial force-independent stent valve device for implantation at native tricuspid annular site without inducing stress on either myocardial tissue or the bioprosthesis. MethodsWe designed a radial force-independent LuX-Valve as a transcatheter bioprosthesis, comprising a stent valve and a delivery system. The device employs a combination of a right ventricle anchoring component, two leaflet-grasping clips, and an atrial disc as a mechanical integrity to immobilize the stent valve device in secure at the native tricuspid annulus. We evaluated the feasibility and safety of implantation of this device in a goat model. ResultsWe successfully implanted LuX-Valves at the tricuspid position through the right atrium in 17 goats. Procedures in 16 cases were safe. Time for the operator to implant the device until immobilization in secure ranged from 3.5 to 10 min. No significant paravalvular leakage was detected by echocardiography during follow-up, up to 180 days. Histopathology showed no evidence of stent fracture and myocardial injury. ConclusionThe results indicated that radial force-independent LuX-Valve was safe and practicable for tricuspid valve implantation with satisfactory prosthetic function.

Combined Transcatheter Tricuspid and Pulmonary Valve Replacement.

For patients with combined tricuspid and pulmonary valve disease, operative intervention carries high mortality risk. Published reports of combined transcatheter tricuspid and pulmonary valve replacement have been limited to single cases. A retrospective chart review was performed including all patients undergoing combined transcatheter tricuspid and pulmonary valve replacement at the Ahmanson/UCLA Adult Congenital Heart Disease Center. Combined transcatheter tricuspid and pulmonary valve replacement was undertaken in five adult patients (median age: 46 years; range: 24-64 years). Three had congenital heart disease and two had carcinoid syndrome. Four patients had previous surgical tricuspid valve replacement and one had a surgical incomplete annuloplasty ring. Four patients had previous surgical pulmonary valve replacement and one had a right ventricle-to-pulmonary artery homograft conduit. Two patients underwent Medtronic Melody valve implantation in both tricuspid and pulmonary positions and three underwent Edwards Sapien S3 implantation in both tricuspid and pulmonary positions. Valve implantation was successful in all. Follow-up ranged from 0.9 to 3.0 years. One patient underwent redo transcatheter tricuspid valve replacement 12 months after the first transcatheter intervention for progressive regurgitation of a Melody valve. This patient died 2.5 years after combined valve placement of complications from refractory heart failure. The remaining patients were alive and free of valve reintervention at follow-up. Combined transcatheter tricuspid and pulmonary valve replacement can be performed successfully, with an acceptable complication rate. This strategy is a feasible option for appropriately selected patients.

P1149Subcutaneous implantable cardioverter-defibrillator when Transvenous ICD is not a viable option

Abstract Funding Acknowledgements NO FUNDING OnBehalf RHYTHM DETECT Registry Background The class of recommendation for S-ICD implantation in patients who have inadequate vascular access is I according to AHA-ACC-HRS Guidelines and IIb according to ESC Guidelines. Data are lacking about the use of S-ICD for patients in which a transvenous ICD is not a viable option because of the inability to deploy a transvenous lead. Purpose To describe current practice and to measure outcomes associated with S-ICD use in patients in which a transvenous ICD is not a viable option. Methods 942 consecutive patients underwent S-ICD implantation at 22 Italian centers from 2014 to 2019. We identified 101 (11%) patients who received S-ICD because of the reported impossibility of deploying a transvenous lead. Results 21 patients presented with inadequate vascular access but no previous device in place. One patient had a mechanical prosthesis in tricuspid position. The remaining 79 patients received the S-ICD after removal of a prior system implanted, and venous occlusion was diagnosed after lead extraction, or partially or completely failed lead removal. In 24 of these patients a functional transvenous pacing system was left in place for persisting pacing needs. Patients were 60 ± 15 years old, 85% were male, 77% had ischemic or non-ischemic dilated cardiomyopathy, ejection fraction was 36 ± 13%. At implantation, acute conversion test was performed in 64 patients and shock energy of ≤65J was successful in 62 (96.9%) patients. During a median follow-up of 18 months, 6 patients died for non-device related reasons and 1 patient underwent heart transplantation. One patient underwent device replacement for battery depletion and one patient underwent leadless pacemaker implantation. Minor complications (hematomas not requiring system revision) were reported in 2 patients. Appropriate therapies were delivered in 4 patients and 8 patients experienced inappropriate therapies (in 3 patients due to double counting during pacing); all resolved with device reprogramming. Conclusions: In current clinical practice, a minority of S-ICD patients receive the device because of inadequate vascular access. The profile of these patients is similar to that of the typical ICD population in the context of primary sudden death prevention, but many of them present with pacing indications. Acute and mid-term efficacy of S-ICD seemed high. Few complications occurred during follow-up. Particular attention must be paid to device programming for those patients with concomitant pacing systems, in order to prevent inappropriate therapies.

Acute In Vivo Functional Assessment of a Biodegradable Stentless Elastomeric Tricuspid Valve.

Degradable heart valves based on in situ tissue regeneration have been proposed as potentially durable and non-thrombogenic prosthetic alternatives. We evaluated the acute in vivo function, microstructure, mechanics, and thromboresistance of a stentless biodegradable tissue-engineered heart valve (TEHV) in the tricuspid position. Biomimetic stentless tricuspid valves were fabricated with poly(carbonate urethane)urea (PCUU) by double-component deposition (DCD) processing to mimic native valve mechanics and geometry. Five swine then underwent 24-h TEHV implantation in the tricuspid position. Echocardiography demonstrated good leaflet motion and no prolapse and trace to mild regurgitation in all but one animal. Histology revealed patches of proteinaceous deposits with no cellular uptake. SEM demonstrated retained scaffold microarchitecture with proteinaceous deposits but no platelet aggregation or thrombosis. Explanted PCUU leaflet thickness and mechanical anisotropy were comparable with native tricuspid leaflets. Bioinspired, elastomeric, stentless TEHVs fabricated by DCD were readily implantable and demonstrated good acute function in the tricuspid position.

Combined Valve Operations in the Aortic and Mitral Positions With or Without Added Tricuspid Valve Repair

There is limited clinical evidence on when to address tricuspid regurgitation in patients with aortic and mitral valve disease requiring surgical intervention. In this study, we aimed to investigate the potential added value of performing a tricuspid valve repair concomitantly in patients requiring double valve surgery (DVS) of the aortic and mitral valves. We reviewed 223 cases of multivalve surgery from 2011 to 2016. In this single-institution series, 190 underwent DVS in aortic and mitral positions and 33 had triple valve surgery in aortic, mitral, and tricuspid positions. Preoperative and postoperative echocardiograms were evaluated to determine changes in valve function. A logistic regression model was performed to assess relationship of patient comorbidities and type of valve operations to perioperative adverse events. Mid-term survival was similar between the 2 groups (P = 0.541). Compared to DVS, TVS was not associated with an increased risk of perioperative adverse events, including need for pacemaker or mortality on multivariable analysis. Within the DVS subgroup, 19.8% of patients experienced improvement in tricuspid valve function with decrease in the degree of tricuspid regurgitation within a 6-month postoperative follow-up. Our study indicates that repairing the tricuspid valve while addressing the aortic and mitral valves does not pose significant additional risk. The observed improvement of the degree of tricuspid regurgitation without tricuspid operation suggests the need to further define subpopulations of patients with multivalvular disease.

P4720Mitraclip XTR device used for the treatment of functional tricuspid regurgitation provides significant reduction of annular size

Abstract Background Tricuspid valve regurgitation (TR) is a progressive disease strongly associated with increased cardiac and all-cause mortality. The transcatheter approach to this pathology has been recently described with promising results in the treatment of symptomatic patients despite optimal medical therapy. Development of annular dilation and leaflet tethering represent a continuous pattern in the pathophysiology of functional TR; for this reason, to reduce and stabilize the annulus is the goal of an efficacious therapy. Purpose In order to simplify leaflet grasping, the novel MitraClip XTRdevice has significantly longer clip arms compared to its predecessor. The increased grasping length could be able to apply a radial tension on the tricuspid annulus, reducing it in dimensions. Despite, the increased tension on the leaflets may theoretically impose a higher risk for leaflet tearing We analyzed our single-center experience in order to clarify the capability of the device in the feature of annular reshapement. Methods Five high-risk patients (4 females, 72 (quartiles 69–79) y.o., EuroSCORE II 10 (7.25–11.2)% affected by severe symptomatic functional TR were treated with MitraClip XTR implantation in tricuspid position. Right ventricular function was apparently preserved in all cases and the mean sPAP was 41 (quartiles 38–45) mmHg. Perioperative echo-results were collected prospectively and analyzed. Results Procedural success (defined as a reduction of more than 1 degree of TR) was achieved in 4 cases (80%). 3±1 devices were implanted per patient in the antero-septal commissure. The tricuspid annular diameter (measured in four chamber view) was reduced from 39 (quartiles 39–41) mm to 31 (quartiles 30–31) mm (p=0.043). Accordingly, the effective regurgitant orifice area (EROA) decreased from 110 (quartiles 70 to 160) mm2 to 45 (quartiles 9–55) mm2 (p=0.02) and the systolic VTI in the hepatic veins decreased by 42%. No significant increase of trans-valvular mean gradients was observed (2.5 (quartiles 2.25 to 2.75)) mmHg vs 3.75 (quartiles 3,75 to 4) mmHg; p=0.2) as well no cases of acute leaflet tearing. Conclusion The reduction in tricuspid annulus size with the novel XTRdevice represents an unexpected and interesting achievement of the procedure. A significant reduction of annular dimensions might provide a more durable reduction of functional TR. Long-term follow-up data will be required to clarify these initial results and as well as patient selection criteria.