Reduction of ‘v’ waves of Severe Tricuspid Regurgitation During the Treatment of Cardiogenic Shock with Edge-to-Edge MitraClip Technique
Presenter
Sarah Harirforoosh, The University of California, Irvine Medical Center, Orange, CA
Sarah Harirforoosh1, George Nasr1, Kevin Chen1, Michael Johl2, Elvis Cami, MD3, David M. Shavelle, M.D.4 and Morton J. Kern, M.D., MSCAI5, (1)The University of California, Irvine Medical Center, Orange, CA, (2)The University of California, Irvine Medical Center, Santa Rosa, CA, (3)Beaumont Hospital - Royal Oak, Royal Oak, MI, (4)Long Beach Memorial Medical Center, Manhattan Beach, CA, (5)Long Beach VA Health Care System, Long Beach, CA
Keywords: Cardiogenic Shock, Heart Failure, Structural Heart Disease (SHD) and TTVR/Tricuspid Valve
Introduction There is a paucity of clinical data supporting the efficacy of transcatheter treatment of severe tricuspid regurgitation (TR), especially in the acute setting. Here we describe the hemodynamics and clinical resolution in a patient with cardiogenic shock secondary to severe symptomatic TR unresponsive to inotropes and diuretics managed by successful transcatheter edge-to-edge repair (TEER) of the tricuspid valve. Clinical Case A 60-year-old man with non-ischemic cardiomyopathy (ejection fraction of 25-30%) presented with worsening leg edema, orthopnea, and abdominal distention. A BNP level was elevated (1084 pg/mL), and elevated liver enzymes were consistent with hepatic congestion. A transthoracic echocardiogram revealed his previously reduced ejection fraction of 25-30% but now with new evidence of severe tricuspid regurgitation with a large central jet, dilated IVC to 2.86cm, and systolic flow reversal noted in the hepatic veins (Figure 3A-C). Despite institution of intravenous diuretics, refractory symptoms and continued signs of volume overload with a rising creatinine prompted right heart catheterization. The results are shown in Table 1 and Figure 4A-D. Because of continued hypotension and low cardiac index, the patient was started on an intravenous infusion of milrinone. A heart team evaluation found him to be a poor surgical candidate for surgery and referred him for TEER with the MitraClip system (Abbott Vascular, Santa Clara, CA, USA). The procedure technique is outlined in the attached PowerPoint. Mean right atrial pressure improved to 23 mmHg, s wave was reduced to 27 mmHg with a less prominent y descent of 8 mmHg (Figure 5A-B and Table 2), and reduction of the S wave of TR. Continuous-wave doppler showed a mean gradient across the tricuspid valve of 4 mmHg with a reduction in TR to moderate in severity (Figure 6A-B). Discussion The 2020 ACC/AHA Heart Valve Disease guidelines present a class I indication for surgical repair for severe TR at the time of left-sided valve surgery, and level 2A indication for isolated severe TR intervention only with evidence of significant right ventricular dysfunction. Evidence supporting these recommendations, however, is limited due to the lack of data from randomized controlled trials with a noted increase of perioperative adverse events. Evidence showing the efficacy of percutaneous tricuspid repair in severe TR has been emerging over the years, particularly for the edge-to-edge technique with the MitraClip system. Currently, the TriClip system from Abbott is undergoing investigation for percutaneous repair for TR in the United States. With the TRILUMINATE clinical trial underway, preliminary data has shown that it is safe and effective in treating moderate-severe symptomatic TR with outcomes 6 months after randomization suggesting significant improvement in TR reduction and quality of life. In summary, severe, symptomatic TR can be successfully treated with edge-to-edge repair with the MitralClip system. Percutaneous repair is a safe and viable alternative to surgical repair for patients with symptomatic severe TR in cardiogenic shock, who are otherwise too high risk for surgical repair.