Background Transcatheter tricuspid valve repair (TTVR) is an emerging option for treating high-grade tricuspid regurgitation (TR) [1], mostly performed by edge-to-edge repair, and always guided by transesophageal echocardiography (TOE). In patients with excellent acoustic window, transthoracic echocardiography (TTE) can also provide a comprehensive understanding of tricuspid valve (TV) morphology [2]. Also, in TTVR there is no need for transseptal puncture. Purpose We sought to determine if TTVR can be successfully conducted by a novel TTE guiding approach, in conjunction with fluoroscopy [3]. Methods 30 consecutive patients, scheduled for TTVR, were assigned to a TTE group (n=10), in the presence of excellent acoustic window, and a TOE group (n=20). On top of fluoroscopy, TTVR was guided exclusively by TTE in the first group, with TOE result confirmation solely upon clip release, due to safety reasons. The second group underwent classical TOE guidance. Understanding the 4 right heart chamber views (Fig. 1) and their respective fluoroscopic angulations was paramount. TR severity, parameters of quality of life and functional capacity were assessed and compared between-groups, at baseline and 30 days. Results Except for lower BMI (TTE 22.3±0.8 vs TOE 29.8±4.3, p<0.001), other baseline characteristics were very similar between groups, e.g., age (81.7±3.9 vs 82.8±4.1, p=0.483) or EuroSCORE II (11.9±10.3 vs 10.4±8, p=0.692).Device success was achieved in all patients, with a total of 15 implanted clips in the TTE group (mean no. of clips / patient 1.5±0.7) and 31 clips in the TOE group (1.5±0.6). Device time (75±37.1 vs 65.7±31.3 minutes, p=0.506) and fluoroscopy duration (16.3±10.5 vs 14.4±7.2 minutes, p=0.564) were also close. TR reduction was successful in all but one patient, in each group (90% vs 95%, p=1.000). TR improvement was equal between-groups, with 2 or more grade reduction in 60% of each group, at 30 days. Thus, grade IV/V and V/V TR, present in 60% of all patients at baseline, dropped to 10% (9/10 vs 18/20, p=1.000) by procedure end and follow-up (Fig. 2). No device associated complications occurred. By 30 days, there was one non-cardiac death and one major bleeding. At follow-up, all but one patient had at least one grade reduction in NYHA class (10/10 vs 19/20, p=1.000). Kansas City Cardiomyopathy Questionnaire score and 6-minute walk distance similarly improved (Δ20.7±14.9 vs 15.5±7.9 points, p=0.227; Δ80.5±60.1 vs 46.6±30.6 meters, p=0.121). A statistical in-group difference was also noticed in renal function improvement by follow-up [glomerular filtration rate (GFR) TTE group 56.8±18.7 vs 64.8±12.5 ml/m2/1.73 m2, p=0.028; TOE group 50.7±19.9 vs 62.2±25.9, p=0.001]. Conclusion TTE guidance of TTVR is feasible in selected patients with excellent acoustic window and could offer an alternative in case of high anesthetic risk. Similar procedural success and clinical outcomes, as with TOE guidance, can be achieved. Funding Acknowledgement Type of funding sources: None.
Funding Acknowledgements Type of funding sources: None. Background Transcatheter edge-to-edge tricuspid valve repair (TTVR) for tricuspid regurgitation (TR) is an emerging treatment option in inoperable patients. TTVR is always guided by transesophageal echocardiography (TOE) and performed under general anesthesia. In patients with excellent acoustic window, transthoracic echocardiography (TTE) can also provide a comprehensive morphological understanding. Moreover, in TTVR there is no need for transseptal puncture. Purpose We investigated if TTVR can be successfully conducted by a novel TTE guiding approach, in conjunction with fluoroscopy, based on the concept of the 4 right-sided chamber views. Methods Thirty TTVR patients were assigned to a TTE (n=10) and a TOE group (n=20), depending on acoustic window and corresponding guidance. Multimodality imaging was paramount for procedural planning and included TTE, TOE and cardiac CT, from which the corresponding fluoroscopic angulations of the 4 right-sided chamber views were derived. Thus, interventionalists and cardiac imaging specialists were assessing the same chamber views from their respective imaging modality. TR severity and quality of life parameters were assessed at baseline and up to 12 months. Results Except for lower BMI (TTE 22.3±0.8 vs TOE 29.8±4.3, p<0.001), baseline characteristics were similar between groups e.g., age (81.7±3.9 vs 82.8±4.1, p = 0.483) or EuroSCORE II (11.9±10.3 vs 10.4±8, p = 0.692). Device success was achieved in all patients, with a total of 15 implanted clips in the TTE (clips / patient 1.5±0.7) vs 31 clips in the TOE group (1.5±0.6), and device times of 75±37.1 vs 65.7±31.3 minutes (p = 0.506). TR reduction was successful in all but one patient, in each group (90% vs 95%, p = 1.000). TR improvement was equal between-groups, with 2- or more grade reduction in 60% of cases, at 30 days. No device associated complications occurred. Nine patients in the TTE group and 17 in the TOE group completed one-year follow-up. Quality of life and functional capacity similarly improved in both groups, with NYHA class reduction in all survivals [100% (9/9) vs 95% (17/17), p = 1.000], and significant improvement in KCCQ score and 6-minute walk distance in each respective group (∆24.8±21.4 vs 20.1±13.6 points, p = 0.227; ∆93.5±100.4 vs 80.8±64 meters, p = 0.121). TR reduction impacted major organs e.g., liver and kidney. Thus, glomerular filtration rate (GFR) increased [TTE group 56.8±18.7 vs 64.6±14.9 ml/m2/1,73m2, p = 0.050; TOE group 50.7±19.9 vs 53.8±20.9, p = 0.347], while liver congestion parameters decreased e.g, aspartate aminotransferase (AST) [TTE group 28.6±7.5 vs 26.2±8.6 U/L, p = 0.274; TOE group 33.1±5.8 vs 23.6±9, p = 0.388]. Conclusions TTE guidance of TTVR is feasible in selected patients with excellent acoustic window and represents an alternative to TOE or, in combination, may facilitate transition to conscious sedation. Successful TTVR leads to improvement in quality of life, symptom control, and multiorgan function.
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