Functional and structural Tricuspid Regurgitation after TAVI with subsequent AV block III and pacemaker implantation: How should I treat?

The invited Expert's opinion

Volker Rudolph

@VRudolph_HDZ

Interventional cardiologist / Cardiologist

Heart and Diabetes Center NRW - Bad Oeynhausen, Germany

The first important take-home message from this case is to screen for new or worsened tricuspid regurgitation (TR) after a trans-tricuspid lead placement. Worsening of TR by at least one grade following cardiac implantable electronic device (CIED)-implantation is described in up to 45% of cases¹. Even, if only about one-tenth of these cases may develop clinically relevant TR and probably less than one percent acute tricuspid valve injury, the clinical consequences associated with worsening TR, especially when unrecognized, justify routine echocardiographic screening for worsened TR at discharge and at regular intervals following CIED implantations. Despite the rapidly developing availability of non-surgical treatment options, post-CIED echocardiographic control is only rarely performed to date.
 
In the present case, the patient was highly symptomatic after three months of intensified medical therapy, showing clinical signs and organ dysfunction associated with right heart failure clearly advocating TR treatment. While stand-alone lead removal will not result in resolution of TR in most cases, it is of course an option when TR is diagnosed immediately after lead replacement. In this particular case however, TR was not only related to lead interference but also to chordal rupture, making it unlikely that lead removal without tricuspid valve treatment would be an adequate treatment approach.

When considering the options for addressing TR in this patient, surgery is clearly not a good choice because of a predicted in-hospital mortality in this patient of 34% corresponding to the reported TRISCORE of 7².
 
Transcatheter tricuspid repair can be performed with high efficacy and safety in patients with CIED-leads³. In fact, CIED leads were present in 16% of patients treated in the TRILUMINATE trial⁴. However, as rightfully pointed out in the present case report, the posterior chordal rupture along with the shadowing caused by the lead in this region pose a relevant risk for not achieving an optimal result when performing transcatheter repair.

Orthotopic transcatheter tricuspid valve replacement (TTVR) therefore appears as a very promising alternative, given its high efficacy for treating TR. Besides the default screening work-up for anatomical suitability for TTVR and the chosen EVOQUE system, several aspects which are particular to the present case should be considered.

As very nicely demonstrated by the provided material, imaging plays a key role in ensuring a successful procedure. Especially, in a patient with several previously implanted devices (TAVI, pacemaker lead) it is crucial to check for echocardiographic transesophageal and trans-gastric windows that allow high-quality three-dimensional multiplanar reconstruction images, such as the ones shown. As an additional aspect, especially in patients with a high arteriosclerotic burden checking for venous tortuosity which might make the procedure more difficult is a sensible thing to do.

While damages to the lead by TTVR are only encountered infrequently, device interrogation should be routinely performed not only at discharge but also at more regular intervals than usual during follow-up, as experiences with delayed lead damage are still limited.

Postinterventional anticoagulation is still a matter of debate. The authors chose a dual therapy using a NOAC and clopidogrel which might be an appropriate individualized choice in a patient with high arteriosclerotic burden and multiple devices. Overall, the relevant risk of bleeding in the sick population of patients undergoing TTVR has led to a tendency by most operators to restrict postinterventional anticoagulation to mono-therapy, which in most cases means that the pre-existing NOAC is continued after TTVR.

Taken together, this report underlines the potential of TTVR as a highly efficient treatment option in a case, which is not at all trivial and which just a few years ago would have had very limited options. Careful patient selection and interdisciplinary evaluation, such as here performed, are the basis for performing a successful procedure and achieving a relevant clinical benefit for the patient.

1. Gelves-Meza J, Lang RM, Valderrama-Achury MD, Zamorano JL, Vargas-Acevedo C, Medina HM et al. Tricuspid Regurgitation Related to Cardiac Implantable Electronic Devices: An Integrative Review. J Am Soc Echocardiogr. 2022; 35:1107-1122. Gelves-Meza J, Lang RM, Valderrama-Achury MD, Zamorano JL, Vargas-Acevedo C, Medina HM et al.
2. Dreyfus J, Audureau E, Bohbot Y, Coisne A, Lavie-Badie Y, Bouchery M et al. TRI-SCORE: a new risk score for in-hospital mortality prediction after isolated tricuspid valve surgery. Eur Heart J. 2022; 43:654-662. Dreyfus J, Audureau E, Bohbot Y, Coisne A, Lavie-Badie Y, Bouchery M et al.
3. Andreas M, Burri H, Praz F, Soliman O, Badano L, Barreiro M et al. Tricuspid valve disease and cardiac implantable electronic devices. Eur Heart J. 2024; 45:346-365. Andreas M, Burri H, Praz F, Soliman O, Badano L, Barreiro M et al.
4. Sorajja P, Whisenant B, Hamid N, Naik H, Makkar R, Tadros P et al. Transcatheter Repair for Patients with Tricuspid Regurgitation. N Engl J Med. 2023. Sorajja P, Whisenant B, Hamid N, Naik H, Makkar R, Tadros P et al.
5. Hahn RT, Makkar R, Thourani VH, Makar M, Sharma RP, Haeffele C et al. Transcatheter Valve Replacement in Severe Tricuspid Regurgitation. N Engl J Med. 2024. Hahn RT, Makkar R, Thourani VH, Makar M, Sharma RP, Haeffele C et al.