Image – Interventional flashlight

DOI: 10.4244/EIJ-D-20-01295

Transcatheter tricuspid valve repair with the modified TriClip/MitraClip G4 system

Neil P. Fam1, MD, MSc; Faeez M. Ali1, MD; Magdi Hassanin1, MD; Geraldine Ong1, MSc, MD

Figure 1. TTVr with the modified TriClip/MitraClip G4 system. A) Baseline transoesophageal echo (TEE) 150-degree view demonstrating large posterior leaflet flail. B) Baseline TEE 150-degree view with colour Doppler demonstrating torrential tricuspid regurgitation (TR). C) 3D TEE view demonstrating posterior leaflet flail. D) TEE 150-degree view of leaflet grasping with the MitraClip G4 XTW. E) Post-procedural TEE 150-degree view demonstrating moderate TR. F) 3D TEE view demonstrating tissue bridge and elimination of posterior flail. A: anterior leaflet; P: posterior leaflet; RA: right atrium; RV: right ventricle; S: septal leaflet. Blue arrow indicates flail posterior leaflet, orange star indicates TriClip XT between anterior and septal leaflets, blue star indicates MitraClip G4 XTW between posterior and septal leaflets.

Figure 1. TTVr with the modified TriClip/MitraClip G4 system. A) Baseline transoesophageal echo (TEE) 150-degree view demonstrating large posterior leaflet flail. B) Baseline TEE 150-degree view with colour Doppler demonstrating torrential tricuspid regurgitation (TR). C) 3D TEE view demonstrating posterior leaflet flail. D) TEE 150-degree view of leaflet grasping with the MitraClip G4 XTW. E) Post-procedural TEE 150-degree view demonstrating moderate TR. F) 3D TEE view demonstrating tissue bridge and elimination of posterior flail. A: anterior leaflet; P: posterior leaflet; RA: right atrium; RV: right ventricle; S: septal leaflet. Blue arrow indicates flail posterior leaflet, orange star indicates TriClip XT between anterior and septal leaflets, blue star indicates MitraClip G4 XTW between posterior and septal leaflets.

A 57-year-old woman presented with progressive New York Heart Association (NYHA) Class III dyspnoea, oedema and fatigue. Past history included hypertrophic cardiomyopathy with recent implantable cardioverter-defibrillator (ICD) lead extraction due to high impedance, followed by subcutaneous ICD implantation. Echocardiography subsequently demonstrated torrential tricuspid regurgitation (TR) with posterior leaflet flail and a 15 mm flail gap (Figure 1A-Figure 1C, Moving image 1-Moving image 3). The right ventricle (RV) was dilated with normal function; left ventricular (LV) function was preserved with normal pulmonary pressures. After Heart Team review, the patient underwent transcatheter tricuspid valve repair (TTVr) with the modified TriClip™/MitraClip™ G4 system (Abbott Vascular, Santa Clara, CA, USA).

Initial attempts to treat the posterior leaflet flail using a TriClip XT clip were unsuccessful due to the large flail gap. Instead, a TriClip XT clip was placed centrally between the anterior and septal leaflets. Subsequently, a MitraClip G4 XTW clip was inserted into the TriClip guide without miskeying and steered down to the tricuspid valve using the P and L knobs. Using the wider clip, the posterior and septal leaflets were successfully grasped simultaneously, eliminating the flail segment and reducing TR from torrential to moderate (Figure 1D-Figure 1F, Moving image 4-Moving image 6). The patient had an excellent clinical response with improved dyspnoea and was discharged the following day. At one-month follow-up, the patient was in NYHA Class II and echocardiography demonstrated normal RV function with moderate TR, mean gradient 2 mmHg (Moving image 7).

TTVr has recently emerged as a safe and efficacious intervention for patients with severe TR and heart failure1. Worldwide, the majority of TTVr cases have utilised MitraClip NT or XT off-label using a modified steering technique2. The recently introduced TriClip system utilises a dedicated guide catheter with improved steering mechanism to facilitate a coaxial approach to the tricuspid valve. The MitraClip G4 XTW is 50% wider than the XT clip and allows independent leaflet grasping. Here, we implanted a MitraClip G4 XTW off-label using the TriClip guide and a modified steering technique, allowing successful treatment of a patient with challenging tricuspid anatomy. Further device iteration combined with procedural innovation may expand the number of patients eligible for TTVr.

Conflict of interest statement

N. Fam has received speaker honoraria from Abbott Vascular and is a consultant for Edwards Lifesciences. The other authors have no conflicts of interest to declare.

Supplementary data

To read the full content of this article, please download the PDF.

Volume 17 Number 5
Aug 6, 2021
Volume 17 Number 5
View full issue


Key metrics

On the same subject

SPECIAL REPORT

10.4244/EIJV11I13A296 Apr 20, 2016
First transfemoral percutaneous edge-to-edge repair of the tricuspid valve using the MitraClip system
Wengenmayer T et al
free

INTERVENTIONAL FLASHLIGHT

10.4244/EIJ-D-17-00814 Aug 24, 2018
Edge-to-edge repair of a large anterior leaflet notch with severe tricuspid regurgitation
Fam N et al
free

TRICUSPID VALVE INTERVENTIONS

10.4244/EIJV12SYA29 Sep 18, 2016
Transcatheter interventions for tricuspid regurgitation: MitraClip
Schueler R et al
free

INTERVENTIONAL FLASHLIGHT

10.4244/EIJ-D-17-00693 Nov 20, 2017
Transcatheter edge-to-edge repair of lead-associated tricuspid regurgitation
Fam N et al
free

Image – Interventional flashlight

10.4244/EIJ-D-21-00614 Dec 17, 2021
Transfemoral transcatheter tricuspid valve replacement after failed leaflet repair
Wild M et al
free

10.4244/EIJV12I15A292 Feb 3, 2017
The forgotten valve no more
Mylotte D
free

INTERVENTIONAL FLASHLIGHT

10.4244/EIJ-D-18-00672 Oct 12, 2018
Intracardiac echocardiography for guidance of transcatheter tricuspid edge-to-edge repair
Fam N et al
free

Image – Interventional flashlight

10.4244/EIJ-D-18-00956 Mar 20, 2019
FORMA Tricuspid Repair System: device enhancements and initial experience
Asmarats L et al
free
Trending articles
243.1

State of the art

10.4244/EIJ-D-21-01117 Sep 20, 2022
Recanalisation of coronary chronic total occlusions
Di Mario C et al
free
188.65

State-of-the-Art Review

10.4244/EIJ-D-21-01034 Jun 3, 2022
Management of in-stent restenosis
Alfonso F et al
free
169.3

Translational research

10.4244/EIJ-D-21-00824 May 15, 2022
Bench test and in vivo evaluation of longitudinal stent deformation during proximal optimisation
Toth GG et al
free
167.05

Expert review

10.4244/EIJ-D-21-00690 May 15, 2022
Crush techniques for percutaneous coronary intervention of bifurcation lesions
Moroni F et al
free
151.28

State-of-the-Art

10.4244/EIJ-D-22-00776 Apr 3, 2023
Computed tomographic angiography in coronary artery disease
Serruys PW et al
free
110.35

Viewpoint

10.4244/EIJ-E-22-00007 May 15, 2022
TAVI at 20: how a crazy idea led to a clinical revolution
Eltchaninoff H et al
free
X

The Official Journal of EuroPCR and the European Association of Percutaneous Cardiovascular Interventions (EAPCI)

EuroPCR EAPCI
PCR ESC
Impact factor: 6.2
2022 Journal Citation Reports®
Science Edition (Clarivate Analytics, 2023)
Online ISSN 1969-6213 - Print ISSN 1774-024X
© 2005-2024 Europa Group - All rights reserved