Overview of Percutaneous Tricuspid Valve Repair
Tricuspid valve regurgitation and stenosis are rare diseases that affect the heart’s valves. These conditions can often be managed with medication, but sometimes they need more serious treatments, like surgery to fix the valve. Tricuspid valve regurgitation is when the valve doesn’t close properly and causes blood to flow backward in the heart. Tricuspid valve stenosis is when this valve becomes narrow and disrupts the blood flow.
In recent years, a minimally invasive method – transcatheter valve repair – is becoming popular, especially for those who can’t undergo surgery. This approach has been successful on the aortic and mitral heart valves, inspiring doctors to explore more similar techniques to fix the heart valves.
The Tricuspid valve disease can be a direct result of changes in the heart’s structure or a secondary impact from other conditions, like lung diseases, heart muscle diseases or other heart valve diseases. If left untreated, tricuspid regurgitation may cause problems like lowering the heart’s ability to pump blood, increasing blood pressure in the body’s central veins, causing liver congestions, and could even lead to death in severe stages.
This explanation will help you understand tricuspid valve disease and the need for, benefits and risks of the transcatheter valve repair method to treat it.
Anatomy and Physiology of Percutaneous Tricuspid Valve Repair
The tricuspid valve (TV) is the largest of the four heart valves. It’s situated closer to the tip of your heart, compared to a valve known as the mitral valve. It’s the job of the TV to separate the right chambers of your heart — the right atrium and the ventricle. It does this by using a ring of tough tissue, three flaps, two small muscles, and tendons. These valve flaps are commonly known as the anterior, posterior, and septal leaflets.
The tricuspid ring has a complicated structure that’s vastly different from the mitral ring. The shape of this ring can alter under various conditions, so it’s something that doctors keep in mind when they design or place special devices called tricuspid valve rings.
There’s an important area near the TV called Koch’s triangle. This spot is crucial during surgeries because it contains the node that controls the heart’s rhythm (atrioventricular node). Surgeons carefully avoid this triangle and the blood vessels supplying it, to sidestep any rhythm problems in the heart.
TV Regurgitation (TR)
Regurgitation in the TV happens when blood flows back from the right ventricle to the right atrium, instead of the other way. This condition can arise due to several problems, which are divided into primary and secondary categories. Primary causes happen 25% of the time, while secondary causes occur the remaining 75% of the time.
Tricuspid Stenosis (TS)
Stenosis of the TV takes place when the valve becomes narrow. Consequently, not enough blood can flow from the right atrium to the right ventricle. TV stenosis usually happens due to rheumatic heart disease, but it’s rare to see it in isolation.
Patients with TS usually show signs of what’s called venous congestion — you might see a swelling of veins in the neck, fluid collection in the abdomen, swelling in the legs, and fluid accumulation around the lungs. All of these happen because of an increase in the pressure of the right atrium (the top right chamber of the heart). Over time, the right atrium may enlarge and thicken to manage the high pressures. Patients could feel very tired and unwell, or experience reduced pumping efficiency of the heart if the stenosis is severe. A physical examination may reveal a swollen liver and a softer, high-pitched, and shorter sound from the TV during the part of the heartbeat when the heart relaxes and fills with blood.
Why do People Need Percutaneous Tricuspid Valve Repair
If you are having surgery for mitral valve disease (which is a problem with one of the heart’s valves), it’s essential to have an echocardiography. This is an ultrasound test that creates detailed images of your heart. This test allows doctors to measure the tricuspid valve (TV) – another valve in your heart – to see if you need surgery on it too, especially if it’s leaky.
Most people with tricuspid valve disease also have problems with the left side of their heart. Recent research indicates that people with tricuspid valve disease who also have heart failure (when the heart can’t pump enough blood to meet the body’s needs) often don’t live as long. Consequently, these people should be considered for tricuspid valve repair surgery.
If tricuspid valve disease is left untreated for a long time, further surgery can become too risky. This is because the valve disorder can significantly change the body’s structure and how it operates. Many patients considered for tricuspid valve surgery often have a variety of other health problems, making surgery riskier. Therefore, less invasive repair techniques can help increase surgery success rates for these individuals, reducing illness and life-threatening conditions related to the surgery.
There are several specific instances where repair surgery may be needed:
- You have severe tricuspid stenosis (the valve is narrow) with related symptoms, and tests show a gradient greater than 5cm (the difference in blood pressure across the valve) or surface area less than 1 cm.
- You have severe primary or secondary tricuspid regurgitation (the valve is leaky) with symptoms.
- You are having surgery for a valve problem on the left side of your heart, and you have a moderate to severe tricuspid valve issue or mild to moderate secondary tricuspid regurgitation with a dilated (widened) annulus (the ring where the valve attaches).
- You have an infection, called endocarditis, on the tricuspid valve.
- You have progressive enlargement or weakening of the right side of your heart along with a leaky tricuspid valve that doesn’t cause or barely causes any symptoms.
- You have a type of rare cancer (carcinoid) impacting the tricuspid valve.
- You were born with abnormalities of the tricuspid valve.
- You have damage to the valve due to incidental incidents such as surgical complications or due to heart or lung biopsies.
All these conditions need urgent attention. If left untreated, tricuspid valve disease can pose a severe threat to your heart condition and overall health.
When a Person Should Avoid Percutaneous Tricuspid Valve Repair
There are a few reasons why someone might not be able to have a specific surgical procedure. These can include:
Patients who are otherwise fit for surgery but could see more benefits from having a traditional open repair, compared to a less invasive method.
Some people cannot tolerate systemic anticoagulation, which is a treatment that helps to reduce the formation of blood clots in the body. This intolerance can make such procedure risky for them.
Those who have a bleeding disorder with coagulopathy, a condition where blood doesn’t clot properly, are also at risk. Performing surgery on these individuals could lead to excessive bleeding.
Lastly, the presence of a blood clot (thrombus) in the femoral or jugular veins (large veins in the leg and neck), the right atrium (one of four chambers in the heart), or in the vena cavae (the body’s largest veins) can impact the safety of a surgery. Therefore, if a clot is present in any of these areas, the person might not be eligible for the procedure.
Equipment used for Percutaneous Tricuspid Valve Repair
The following tools are needed:
A cardiac catheterization laboratory, also known as a ‘cath lab,’ that includes a fluoroscopy machine. This lab is like a special examination room in a hospital where doctors perform procedures to check the heart and blood vessels. The fluoroscopy machine is like a large X-ray machine that allows doctors to see the heart and blood vessels in real-time.
Devices for transthoracic echocardiography and transesophageal echocardiography. These are types of ultrasound technologies that let doctors look at the heart and its structures from different angles. Think of it as an advanced version of the ultrasound used during pregnancy to see the baby in the womb.
A device for tricuspid valve repair or replacement. This is a tool used to fix or replace a part of the heart called the tricuspid valve, which helps control the flow of blood.
Various sizes of wires and catheters. Catheters are thin, flexible tubes used to carry fluids into or out of the body. Wires help guide the catheters to the right place.
A code cart, which is a set of drawers on wheels that contains medication and equipment needed in case of an emergency.
A sterile gown and gloves and a sterile drape. These items help ensure cleanliness and prevent infection during the procedure.
The assistance of an experienced cardiac surgery team with open surgical trays ready. The trays hold all the sterile tools needed during the surgery.
Anesthesia, which is medicine that helps prevent pain during the procedure.
Who is needed to perform Percutaneous Tricuspid Valve Repair?
Repairing the tricuspid valve (a valve in your heart) through a method called percutaneous repair, needs a team of really skilled healthcare professionals. This team includes:
* An interventional cardiologist, a heart doctor who uses small tools, usually guided by an x-ray or other imaging technique.
* Cardiac nurses, who are trained specially to take care of heart patients.
* Cath lab personnel, these are the nurses and technicians who work in a special room (called a cath lab) where heart procedures are done.
* Cardiothoracic surgeons, these are special surgeons who perform operations on the heart and chest.
* A skilled ultrasonographer, this is a person who uses a machine called an ultrasound to create images of the inside of your body, like your heart.
* Anesthesia team, these are the doctors and nurses who will make sure you are asleep and don’t feel any pain during the procedure.
All these professionals work together to make sure your heart valve repair goes well.
Preparing for Percutaneous Tricuspid Valve Repair
Before a doctor carries out a medical procedure on the tricuspid valve using a catheter or small tube (a process called “endovascular repair” or replacement), it’s important to have a clear idea of the valve’s condition. This is done through an ultrasound scan of your heart, known as an echocardiogram. Doctors recommend a specific type of this exam called a 2D echocardiogram combined with color doppler. This is a non-invasive test that uses sound waves to produce images of your heart in real-time and helps to assess any potential issues related to the valve or the right side of the heart.
The majority of people, around 80% to 90% can be diagnosed using this method, even if valve issues are minor.
However, in some instances, if the doctor cannot clearly see the valve via the 2D echocardiogram, they may use a 3D echocardiogram or a special kind of heart scanning technique called cardiac magnetic resonance. These alternative imaging methods provide a detailed view of the right side of the heart, valve size, and the part of the valve that connects to heart muscle, with no limitations.
Interestingly, not all tricuspid valves are the same. Some people could be diagnosed as having two or more than three leaflets or flaps on the valve. Because of this, a heart specialist may need to review the images from the echocardiogram, whether it’s 2D or 3D.
For the actual procedure, the utmost care is taken to ensure everything is clean and sterile to prevent infection. Everyone in the operating room will be fully dressed in protective clothing, gloves, eyewear, and caps. Protective clothing for radiation (lead aprons) is also worn since X-rays are typically used during the procedure. Before starting, the area on your body where the catheter will be inserted is also carefully cleaned and covered with sterile drapes.
How is Percutaneous Tricuspid Valve Repair performed
The tricuspid valve is a part of the heart that has been overlooked in the past, and there’s some hesitation about treating conditions that only affect it. However, severe issues with the tricuspid valve can lead to serious health problems and should be fixed or replaced. Usually, fixing or replacing the tricuspid valve happens at the same time as other heart procedures.
The current best method for fixing this valve is called “ring annuloplasty”, which is a surgical procedure. This is becoming more common because of the success of similar procedures on the aortic and mitral valves. Similarly, fixing tricuspid stenosis, a narrowing of the tricuspid valve, is usually done with a procedure called endovascular valvotomy or valvuloplasty.
Since not many patients can undergo surgery, there has been new interest in alternative methods to treat tricuspid valve disorders. These are known as percutaneous transcatheter devices which are likely to be used more in the future as technology gets better. These techniques can completely replace the tricuspid valve, or just fix issues. The most important thing before deciding on one of these procedures is choosing the right patient. After the procedures, patients will need to have their heart checked regularly to make sure the valve is performing well.
One of these procedures, Transcatheter Replacement of Tricuspid Valve, is still in the early stages of development and requires a lot more testing. There are a few replacement valves already out there, such as a bioprosthetic xenopericardial valve, which is inserted through a small cut in the chest or neck. This type of replacement is still being studied. Another replacement valve is the nitinol self-expanding valve, which is secured in the heart and is made up of two leaflets that allow the heart to fill with blood and then close to prevent blood from backing up into the heart.
However, there are specific challenges with this type of procedure, such as the placement of the valve and the longevity of the valve, which are both unknown. Also, the location of the heart’s natural electrical system near the valve can cause complications during the procedure. Patients will need to take blood-thinning medication for the rest of their lives due to the risk of blood clots forming on the right side of the heart.
There are also procedures to treat tricuspid regurgitation, when the valve doesn’t close tightly and allows blood to flow back into the heart. There are several new techniques to fix this issue that are still in early trials. For example, a Mitral Valve Clipping System can be used on the tricuspid valve, which can clip the valve allowing it to close tight.
However, these all require careful patient selection and regular heart check-ups after the procedures to ensure that they’re successful over the long term.
Possible Complications of Percutaneous Tricuspid Valve Repair
Having your tricuspid heart valve repaired can result in some complications, whether the doctor reaches your heart through a large cut (or an open repair) or a small tube in your blood vessels (or a transcatheter repair). The chances of not surviving a tricuspid valve replacement are three to four times higher in comparison to most of the other heart valve procedures. Even though heart surgery always comes with risks, the risk of health problems or death during or after surgery may increase to one in ten for some people who have surgery on their tricuspid valve.
Here are some problems that can happen during or after this operation:
1. Problems related to where the thin, flexible tube or catheter is put into the body: For example, it might cause an area of bleeding under the skin (hematoma), a cut in an artery (arteriotomy), a rip in the wall of an artery (dissection), or an abnormal connection between an artery and vein (arteriovenous fistula).
2. Heart attack: This can occur if the right heart artery is damaged or irritated during surgery.
3. Irregular heart rhythms and heart blocks: A rhythm problem can happen if the surgery affects the heart’s normal electrical pathways.
4. Malfunctioning artificial valve: Sometimes, the artificial valve doesn’t work as it should.
5. Heart failure: In this condition, your heart can’t pump enough blood to meet your body’s needs.
6. Bleeding during or after the operation: This could require blood transfusion and result in related complications.
7. Drug reactions: Sometimes, your body might react to the drugs that are used during surgery.
8. Infection: There can be an infection at the spot where the surgery was done or the new valve itself can get infected.
9. Sepsis: This is a dangerous infection that can spread throughout your body.
10. Lung complications: You can develop a collapsed lung (pneumothorax), lung infection (pneumonia) or a blood clot in your lungs (pulmonary embolism) after surgery.
11. Kidney failure:
Sometimes, the dye used during surgery could damage the kidneys causing kidney failure.
12. Stroke: There is a small chance of having a stroke after heart surgery.
Just remember, these complications are not common and doctors try their best to prevent them.
What Else Should I Know About Percutaneous Tricuspid Valve Repair?
It’s relatively new to use a catheter-based procedure to treat issues with the tricuspid valve, which is one of the four valves in your heart. This method avoids the need for open heart surgery (sternotomy) and being hooked up to a heart-lung machine (cardiopulmonary bypass).
Problems with the tricuspid valve have often been overlooked in the past. This is because they’re rare and it’s been assumed they don’t significantly impact a patient’s health. However, not treating these issues can lead to more serious heart problems, and can increase a patient’s risk of disease and death.
So, any significant problems with the tricuspid valve should be addressed by doctors.
