By Laura Freeman
For patients dealing with symptoms of a leaky tricuspid valve, until recently physicians had only limited treatment options to offer. After weighing the risks and benefits of surgery, especially in older patients who have a greater prevalence of the condition, the consensus was usually to try to manage the problem with medications. Any lingering fatigue, burden on heart failure and other health effects were an unfortunate reality. Surgery to correct the leak wasn’t likely to happen unless another heart surgery became necessary and the tricuspid could be repaired at the same time.
Then a couple of years ago, the minimally invasive, image-guided TriClip transcatheter procedure developed by Abbott Laboratories received FDA approval. Baptist Health Cardiovascular Associates was an early adapter of the TriClip Transcatheter Edge to Edge Repair system (TEER), and Matthew Sample MD and Stephen Bakir MD are two of their interventional cardiologists who trained to make this option available to their patients.
In a sense, the four-handed transcatheter procedure is much like a duet written for two virtuoso musicians playing matching grand pianos.
“Unlike some of the more familiar procedures that can be done by one interventional cardiologist, this procedure takes two,” Sample said. “While the interventional cardiologist is guiding the catheter with the TriClip device, the imaging cardiologist is guiding the visual side. We alternate roles on a case by case basis.”
Bakir said, “Since we’re working within the vein and heart itself, we use advanced echoes and transesophageal echoes (TEE) to see what we can’t see directly. We refer to the advanced imaging capability as 4D, because it gives us high definition 3D images in real time. Usually we also use an intracardial echo (ICE). With two catheters and a quite a few details involved, you need two interventional cardiologists who work well together to manage them.”
Sample agreed. “Good communication is essential. If I’m placing the TriClip and connecting the leaflets, I’m relying on Dr. Bakir as a second pair of eyes to keep a close watch on a great deal of input coming in from the imaging. Teams that work together often tend to develop their own shorthand language so we can quickly communicate exactly what is going on.”
The procedure is done under general anesthesia since remaining still with a transesophageal echo in place would be too much for most patients. The device clips two or more of the tricuspid leaflets together, reducing backward blood flow.
“Patients tend to do well,” Sample said. “We usually monitor them overnight and they are back to their usual activities in a couple of weeks. When they come back for their 30-day followup, most report that they are feeling noticeably better with improvements in symptoms like shortness of breath and fluid buildup.”
“Tricuspid regurgitation can be difficult to hear through a stethoscope,” Bakir said. “In a quiet location, someone familiar with the sound can often hear it. Diagnosis is usually made with ultrasound where we can see how serious the leakage is and monitor any changes.”
Not all tricuspid regurgitation is severe enough to require repair. For some cases, medication may be enough. Nonetheless, over the past two years, success rates for TriClip procedures have been high. In addition to improving symptoms, hospitalization rates for heart failure have improved.
