Figure: Normal blood flow through the tricuspid valve compared to tricuspid regurgitation, where blood leaks backward into the right atrium. Credit: © A.D.A.M., Inc.
What Is Tricuspid Regurgitation?
Tricuspid regurgitation (TR) occurs when the tricuspid valve, located between the right atrium and right ventricle, fails to close properly. As a result, blood leaks backward into the right atrium instead of flowing efficiently to the lungs.
Over time, this backward flow increases pressure in the right side of the heart and venous system. Patients may develop:
- Breathlessness, especially with activity
- Swelling of the legs, ankles, or abdomen
- Fatigue and reduced exercise tolerance
- Palpitations or irregular heartbeat
Severe TR is often associated with conditions such as heart failure, pulmonary hypertension, or long-standing atrial fibrillation. If left untreated, it can significantly impair quality of life.
Modern Minimally Invasive Treatment Options
In the past, open-heart surgery was the only definitive treatment. However, many patients with severe TR are elderly or have multiple medical conditions, making surgery high risk.
Advances in structural heart intervention now allow catheter-based treatments without opening the chest or stopping the heart.
1. Tricuspid Transcatheter Edge-to-Edge Repair (T-TEER)
Figure: Transcatheter edge-to-edge repair (TEER) using the PASCAL device, where the valve leaflets are gently brought together to reduce leakage. Credit: Edwards Lifesciences.
Transcatheter edge-to-edge repair (TEER) is currently one of the most commonly used minimally invasive techniques for treating tricuspid regurgitation. The procedure works by improving how the existing valve closes, thereby reducing backward blood flow.
Using the PASCAL system, a small device is delivered to the heart through a catheter inserted via a vein in the groin. Under detailed imaging guidance, the device grasps the valve leaflets and brings them closer together, helping the valve seal more effectively.
T-TEER is generally most suitable for patients whose valve anatomy allows repair. By improving leaflet closure, the procedure can significantly reduce regurgitation and may lead to improvement in symptoms such as breathlessness and leg swelling.
2. Transcatheter Tricuspid Valve Replacement (TTVR)
Figure: Transcatheter tricuspid valve replacement (TTVR) using the EVOQUE valve system, which replaces the diseased tricuspid valve to restore forward blood flow. Credit: Edwards Lifesciences.
In some patients, repairing the tricuspid valve may not be sufficient. When the valve is severely damaged or unsuitable for repair, it can be replaced entirely using a minimally invasive transcatheter approach.
The EVOQUE valve system is specifically designed for the tricuspid position. During the procedure, a replacement valve is delivered to the heart through a catheter inserted via a vein in the groin. The new valve is positioned within the existing tricuspid valve and carefully deployed, where it anchors securely and takes over the function of regulating blood flow.
By replacing the diseased valve, TTVR can significantly reduce, and in some cases, eliminate regurgitation. This may lead to improvement in symptoms such as swelling, fatigue, and breathlessness.
Careful imaging assessment is essential to ensure the valve size and anatomy are suitable for safe implantation.
Doctors may recommend TTVR for patients with:
- Severe or torrential tricuspid regurgitation
- Valve anatomy that is not suitable for repair
- Persistent symptoms despite optimal medical therapy
3. Caval Valve Implantation (CAVI)
Figure: Transcatheter caval valve implantation, where self-expanding valves are placed in the vena cavae to reduce backward venous flow in severe tricuspid regurgitation. Credit: P+F Products & Features.
In some advanced cases of severe tricuspid regurgitation, direct valve repair or replacement may not be suitable due to anatomical or medical considerations.
CAVI takes a different approach. Rather than treating the tricuspid valve itself, the procedure aims to reduce the effects of severe leakage. Using the TricValve system, two self-expanding valves are implanted in the major veins returning blood to the heart:
- The superior vena cava
- The inferior vena cava
These valves help prevent backward flow of blood into the venous system. By reducing excessive venous pressure, CAVI may relieve symptoms related to congestion, such as leg swelling, abdominal bloating, and fluid retention.
Doctors typically recommend CAVI for patients with advanced disease who are not suitable for direct valve repair or replacement.
How Do We Decide Which Treatment Is Appropriate?
Selecting the right therapy depends on:
- Valve anatomy
- Severity of regurgitation
- Right ventricular function
- Overall medical condition
- Surgical risk profile
Comprehensive echocardiography and advanced imaging are essential. An experienced structural heart team carefully reviews each case to ensure the safest and most appropriate approach.
What Patients Can Expect
All three procedures are performed via catheter-based techniques, typically through a vein in the groin.
Compared to open-heart surgery, potential advantages include:
- No sternotomy
- Shorter hospital stay
- Faster recovery
- Reduced procedural risk in selected patients
However, careful patient selection remains critical.
Speak to a Heart Specialist
At The Heart & Vascular Centre, we specialise in structural heart disease and advanced catheter-based treatments. A personalised evaluation by an experienced heart specialist can help determine whether minimally invasive treatment is right for you.
If you or a loved one has been diagnosed with a leaky tricuspid valve, Contact us at The Heart & Vascular Centre and seek specialist advice early to explore the full range of treatment options available.
References:
- Mayo Clinic. 2024, March 12. Tricuspid valve regurgitation. https://www.mayoclinic.org/diseases-conditions/tricuspid-valve-regurgitation/diagnosis-treatment/drc-20350173
- Seligman MA, Vora AN, Haroian NQ, Puri R, Heng EL, Smith RD, et al. The current landscape of transcatheter tricuspid valve intervention. J Soc Cardiovasc Angiogr Interv. 2023;2(6 Pt B):101201. doi:10.1016/j.jscai.2023.101201
- Edwards Lifesciences. (n.d.). PASCAL Transcatheter Valve Repair System. Available at: https://www.edwards.com
- Edwards Lifesciences. (n.d.). EVOQUE Tricuspid Valve Replacement System. Available at: https://www.edwards.com
