Editors' ChoiceCARDIOVASCULAR INTERVENTIONS

Score: N = 1/Tricuspid regurgitation = 0

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Science Translational Medicine  01 Apr 2015:
Vol. 7, Issue 281, pp. 281ec53
DOI: 10.1126/scitranslmed.aab0840

Heart valves ensure that blood flows in the proper direction through the heart, body, and lungs. Should they fail by becoming too tight or too loose, rapid decompensation ensues. Historically such severe disease has required surgery, although minimally invasive approaches are being developed. Most advanced is transcatheter aortic valve replacement, and additional techniques are quickly emerging for mitral valve disease. But severe tricuspid valve incompetence, or regurgitation, has remained a problem with few options. Situated between the right atrium and ventricle, the tricuspid valve, like the mitral valve, is anatomically complex. Surgical repairs often do not last long, and patients with severe tricuspid disease progress to heart and multi-organ failure, with mortality as high as 60% at 5 years.

Schofer et al. have now performed the first successful, direct transcatheter tricuspid valve repair in a ~90-year-old patient with severe tricuspid regurgitation and consequent heart and kidney failure and massive leg swelling. With a surgical mortality risk of >25%, the patient was deemed inoperable. In the absence of other options, physicians obtained regulatory approval for compassionate use of the Mitralign system, a technology designed for percutaneous mitral valve repair. Through an entirely percutaneous approach and advanced imaging techniques, the team successfully tightened the tricuspid valve by using a “bicuspidization" approach. This method cinches off one of the three flaps of the normally “tri”cuspid valve, rendering it “bi”cuspid. After the procedure, the patient’s kidney and heart function (including regurgitant backflow and forward cardiac output) rapidly normalized, allowing the patient to be discharged within 5 days.

Through competence, compassion, and courage on the part of physician and patient, our field position in the management of tricuspid valve disease has shifted overnight. Despite the N of 1, this demonstration will undoubtedly accelerate development of transcatheter tricuspid valve repair technologies for this complex and well-appreciated—but undermanaged—condition.

J. Schofer et al., First-in-human transcatheter tricuspid valve repair in a patient with severely regurgitant tricuspid valve. J. Am. Coll. Cardiol. 65, 1190–1195 (2015). [Abstract]

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