By Lauren Johnson
UAB is among the leading centers in the world for treating tricuspid regurgitation, a condition that occurs when the tricuspid valve in the heart does not close properly, allowing blood to flow backward into the heart.
Mustafa Ahmed, MD, an interventional cardiologist and the director of the cardiovascular network at UAB, has seen amazing advancements in care for structural heart disease over the past several years. Since 2019, Ahmed has been an investigator in most of the major trials for tricuspid valve treatments. He and the UAB tricuspid team continue to be part the of trials, making them one of the first in the country to offer new treatment options for tricuspid regurgitation.
“Things that used to be only treated with open heart surgery can now be taken care of by going through catheters in either veins or arteries,” he said. “Before this, there weren’t many options for patients with tricuspid valve issues. For many of these patients an open-heart operation was too high of a risk.
“This tricuspid journey has been an interesting evolution in the last few years. Unlike the other valves, tricuspid does not have a one-fits-all solution. Over the last 10 years, we’ve gone from having no treatments to suddenly having four to five different solutions.”
When UAB cardiologist Ali Ebrahimi, MD was in training, the tricuspid valve was often called the forgotten valve. Compared to the others, it wasn’t a priority, but when it was left unrepaired, patients continued to suffer from shortness of breath, swollen legs, and fatigue. In some cases, the patient would develop liver disease or RV dysfunction. By that point, they were usually too sick to undergo open-heart surgery again.
Eventually, minimally invasive procedures became available for the tricuspid valve. With advancing technology, medical professionals have learned how to take pictures of this valve, how to measure it, to fix it and how to categorize patients based on their condition. The better they’ve gotten at repairing it, the better they’ve gotten at finding it.
“If we can fix your tricuspid valve, we aren’t necessarily making you live longer, but we can help you feel better and that’s also valuable, especially in your later years,” Ebrahimi said.
The first treatment for the tricuspid valve that became available was the transcatheter edge-to-edge repair, also known as the TriClip. This allows surgeons to use a small clip to pinch the leaflets (flaps of tissue) together to reduce leakage. These clips are designed to stay inside the patient for the rest of their life. Eventually, the clips will grow into the valve, making it very stable.
All the devices are small enough to go through the veins, starting in the leg, and delivering up to the heart or the vena cava. Most patients can walk the same day as the procedure. Ahmed completed the trial for the TriClip procedure a few years ago and it’s now commercially approved.
Because the tricuspid valve is so complex, the TriClip isn’t the answer for all patients. The next treatment that became available was the Evoque transcatheter tricuspid valve replacement (TTVR), where surgeons go through the patient’s leg and put in a whole new heart valve.
“At UAB, we were part of the early feasibility trials. The TTVR is incredible because it eliminates almost all of the leak,” Ahmed said.
Unlike open-heart surgery where patients spend about a week in the hospital to recover, patients who’ve had the TriClip procedure can go home the day after the procedure and patients who’ve had TTVR can go home within one to two days.
The next option for patients is the caval valve implantation (CAVI), a minimally invasive procedure where the surgeon places artificial valves in the inferior and superior vena cava by using the TricValve device. Ahmed and his team have just started enrolling in trials for this procedure.
While the TriClip and Evoque devices are on the market now, Ahmed and Ebrahimi are also doing trials using the Intrepid device and TricValve device, which is a pair of stents that surgeons put in the veins that lead to the heart, moving the valve further upstream. TricValve is used when the valve inside the heart is not fixable. The device is installed before the natural valve so blood can be sorted out by the two prosthetic valves.
“If you have a leaky valve, but the leaflets are close to each other, we can clip,” Ebrahimi said. “If the valve is so far apart that the clip can’t pinch them together and replace it, I think about the Evoque or the Intrepid. If all else fails, and the valve is not salvageable, we can do the TricValve and replace the valve’s location and still give you relief. You have to fail four devices before we say there’s nothing we can do for you, so that’s becoming a rarity.”
“What makes UAB so special at offering these treatments is that we have incredible imaging experts and we have an incredible tricuspid team, including Ebrahimi, Muhammad Amr Sabouni, MD, and Baran Aksut, MD,” Ahmed said.
UAB is one of the few hospitals in the U.S. that offers TTVR and CAVI and the valve program continues to be an international leader. Being an investigator and chosen as a trial site allowed Ahmed to offer treatments to patients that had no other options.
“As a doctor that looks after complex patients, it is amazing to be able to offer them treatments. Without those trials, those patients will be left with no one to help them,” he said. “There is nothing better than when you see someone that needs help, and they’ve been told there’s no options, but you’re able to offer them an option that can transform the quality of life. That’s why we do this job. It’s such a privilege to be able to help people, and it’s such a professional privilege to be able to offer the absolute latest cutting-edge treatments in the world.”