Improving quality of life with the TriClip therapy
Tricuspid regurgitation* is caused by a leak in the tricuspid valve and can be detected in around 65 to 85% of the population. What is compensated for by the heart in the mild stage and therefore often goes unnoticed for a long time, has fatal consequences for health as the severity increases.1 The good news: many sufferers can be successfully helped by a minimally invasive procedure with the TriClip™ from Abbott.
It has been called the "forgotten heart valve", is located in the opening between the right atrium and the right ventricle and usually consists of three (Latin "tri") tissue leaflets: the tricuspid valve. If it is fully functional, its leaflets act like a return valve and ensure that blood flows from the right atrium into the right ventricle, but not back.
However, much more often than expected, the heart valve is leaky and the blood flow is disrupted. In medicine, this is known as tricuspid regurgitation. In rare cases, this is congenital, but is usually the result of a pre-existing condition. These include, for example, diseases of the aortic and/or mitral valve such as aortic valve stenosis, mitral valve stenosis or mitral regurgitation, dysfunction of the left ventricle, atrial fibrillation, pulmonary hypertension or inflammation of the inner lining of the heart (endocarditis). In addition, the competence of the valve may be restricted by a pacemaker lead, for example. In order to continue pumping enough blood into the body, the heart then works all the harder and so tricuspid regurgitation (TR) - as well as mild forms of other heart valve diseases - often remains undetected at an early stage. However, if left untreated, tricuspid regurgitation progresses over time. But that's not all: the heart muscle thickens due to the constant extra work. In addition, the pressure in the right heart increases, which causes the right ventricular wall to expand. This causes heart chambers to enlarge and the valve leaflets to be pulled apart. Over time, the heart is no longer able to compensate for the backflow of blood through the defective "valve" and becomes weaker and weaker. Performance and quality of life increasingly decline. The fatal thing is that the first symptoms of this heart disease are often only attributed to the ageing process and not examined by a doctor. As a result, many patients with tricuspid regurgitation are not diagnosed until the disease is already advanced and they are admitted to hospital as a high-risk patient or emergency.2
In the over 65 age group, one in 30 people suffers from moderate to severe tricuspid regurgitation. Women are significantly more frequently affected than men. In many cases, mitral regurgitation is present in addition to tricuspid regurgitation.4,5,6,7
How are heart valve disease and heart failure related?
If one of the valves no longer closes properly, this puts a lot of strain on the heart, as blood keeps flowing back and the heart's pumping capacity decreases. It has to work harder to transport the same amount of blood. This constant strain can lead to heart failure. People who already suffer from heart failure can also have heart valve insufficiency, which then exacerbates the symptoms of the existing heart failure.
Stenosis, i.e. the narrowing of a heart valve, often due to calcification, can also cause heart failure because only a small amount of blood can pass through the opening with each heartbeat.
Early diagnosis improves the prognosis
The fact that in 36% of patients, untreated severe tricuspid regurgitation develops into a life-threatening condition within a year4 shows how important is early diagnosis and treatment of tricuspid regurgitation. During a regular health check-up, the family doctor should always listen for heart murmurs caused by the backflow of blood into the right atrium. If the result of the listening is conspicuous and/or typical symptoms such as shortness of breath, fatigue or fluid retention (oedema) in the legs and feet occur, a referral to a cardiology practice is advisable. There, the suspicion will be investigated using various procedures.
Overview of diagnostic procedures:
- Electrocardiogram examination (ECG)
This records the electrical activity of the heart and makes it possible to detect an abnormal heartbeat, e.g. due to atrial fibrillation. However, tricuspid regurgitation is usually very unspecific in the ECG. - Echocardiogram
With this special ultrasound examination of the heart, the doctor can see the return flow of blood from the right ventricle into the right atrium and the enlargement of the right atrium and even assess why the tricuspid valve is leaking and how severe the leak is. The echocardiogram can be performed from the outside (transthoracic echocardiography) and also from the inside via the oesophagus (transoesophageal echocardiography). In a colour Doppler echocardiogram, the blood flowing back is shown in colour. - Further imaging examinations (X-ray, CT, MRI)
As the heart tries to compensate for the lack of pumping capacity, it is often enlarged in the case of tricuspid regurgitation. A doctor can recognise this on an X-ray or with other radiological heart examinations. - Examination of blood tests
Various parameters in the blood can indicate heart disease and provide information on heart function. These include, for example, the natriuretic peptides BNP and NT-proBNP as well as cardiac troponin
Important to know: There are various classification systems for categorising tricuspid regurgitation according to its severity. An increasingly used system is the grading into five levels: 0 = no TR, 1 = mild TR, 2 = moderate TR, 3 = severe TR, 4 = massive TR, 5 = torrential TR.1 And the higher the severity, the higher the risk of death.8 If heart failure is also present, it is classified according to the criteria of the New York Heart Association (NYHA) into the severity grades NYHA class 1 to 4 class.4
Tricuspid regurgitation: effective treatment of symptoms and causes
Drug therapy, e.g. with dehydrating agents (diuretics), is used to alleviate symptoms such as water retention (oedema). Other medications are used to treat pre-existing/concomitant conditions, such as beta blockers, calcium antagonists, ACE inhibitors or blood thinners. However, the cause of tricuspid regurgitation cannot usually be remedied with medication. Surgical intervention, e.g. repair or complete replacement of the tricuspid valve, is the method of choice for patients who are eligible for surgery due to their clinical picture and general physical condition.2,5,6
Minimally invasive tricuspid valve repair with the TriClip™ A gentler procedure is available as an alternative to surgery for patients for whom surgery would be too risky: catheter-based tricuspid valve edge-to-edge repair (T-TEER)11,12 with the TriClip™ from Abbott. This minimally invasive procedure uses a steerable guiding catheter system and is guided to the heart via the groin. The system was specially developed for the treatment of the tricuspid valve and enables the physician to grasp the tricuspid valve leaflets and bring them together with the TriClip™. Clipping pulls the leaflets together, fixes them and significantly reduces the leakage of the opening between the right atrium and the right ventricle. The TRILUMINATE™, TRILUMINATE™ Pivotal trial and bRight clinical real-world registry confirm an implantation success rate of almost 100% and show that TriClip™ reduces the severity of tricuspid regurgitation, reduces hospital admissions and is associated with a significant improvement in performance and quality of life.12,13,14,15,16 High-risk patients in particular can benefit from the mini-invasive procedure.2,11,12
*Insufficiency (opposite of Latin sufficere 'to suffice') means inadequacy, inability or weakness
- References
- Sorajja P, Whisenant B, Hamid N et al. Transcatheter Repair for Patients with Tricuspid Regurgitation. N Engl J Med. 2023;388(20):1833-1842.
- German Society of Cardiology - Cardiovascular Research e.V., Tricuspid valve regurgitation, DGK position paper, Cardiology 2022;-16:372-382.
- Initiative Herzklappen e.V., "Heart valve diseases in Germany. Faster to effective treatment", 2023. Available online at: initiative-herzklappe.de/publikationen/
- Gesund.bund.de, Heart valve disease, available online at: gesund.bund.de/herzklappenerkrankung
- Topilsky Y. Tricuspid valve regurgitation: epidemiology and pathophysiology. Minerva Cardioangiol. 2018;66(6):673-679.
- Topilsky Y, Maltais S, Medina Inojosa J et al. Burden of Tricuspid Regurgitation in Patients Diagnosed in the Community Setting. JACC Cardiovasc Imaging. 2019;12(3):433-442.
- Beckmann A, Meyer R, Lewandowski J et al. German Heart Surgery Report 2019: The Annual Updated Registry of the German Society for Thoracic and Cardiovascular Surgery. Thorac Cardiovasc Surg. 2020;68(4):263-76.
- Singh JP, Evans JC, Levy D et al. Prevalence and clinical determinants of mitral, tricuspid, and aortic regurgitation (the Framingham Heart Study). Am J Cardiol. 1999;83(6):897-902.
- Nath J, Foster E, Heidenreich PA. Impact of tricuspid regurgitation on long-term survival. J Am Coll Cardiol. 2004;43(3):405-409.
- German Medical Association (BÄK), National Association of Statutory Health Insurance Physicians (KBV), Association of the Scientific Medical Societies in Germany (AWMF). National Disease Management Guideline Chronic Heart Failure - Long version. Version 4.0. 2023 [cited: YYYY-MM-DD]. DOI: 10.6101/AZQ/000510. www.leitlinien.de/herzinsuffizienz.
- Vahanian A et al. 2021 ESC/EACTS Guidelines for the management of valvular heart disease. Eur Heart J. 2022;43(7):561-632.
- German Society of Cardiology e.V. Pocket Guideline Valvular Heart Disease, Version 2021, Börm Bruckmeier Verlag.
- Nickenig G, Weber M, Lurz P, et al. Transcatheter edge-to-edge repair for reduction of tricuspid regurgitation: 6-month outcomes of the TRILUMINATE single-arm study. Lancet. 2019;394(10213):2002-2011.
- von Bardeleben RS, Lurz P, Sorajja P et al. Two-Year Outcomes for Tricuspid Repair With a Transcatheter Edge-to-Edge Valve Repair From the Transatlantic TRILUMINATE Trial. Circ Cardiovasc Interv. 2023;16(8):e012888.
- Arnold SV, Goates S, Sorajja P et al. Health Status After Transcatheter Tricuspid Valve Repair in Patients With Severe Tricuspid Regurgitation. J Am Coll Cardiol. 2024;83(1):1-13.
- Lurz P, Besler C, Schmitz T et al. Short-Term Outcomes of Tricuspid Edge-to-Edge Repair in Clinical Practice. J Am Coll Cardiol. 2023;82(4):281-291.
- Lurz P, von Bardeleben RS, Weber M, et al. Transcatheter Edge-to-Edge Repair for Treatment of Tricuspid Regurgitation. J Am Coll Cardiol. 2021;77(3):229-239.
- German Society of Cardiology - Cardiovascular Research e.V., Tricuspid valve regurgitation, DGK position paper, Cardiology 2022;-16:372-382.
Further links:- Initiative Herzklappen e.V., "Herzklappen-Erkrankungen in Deutschland. Faster to effective treatment", 2023. Available online at: initiative-herzklappe.de/publikationen/
- Gesund.bund.de, Heart valve disease, available online at: gesund.bund.de/herzklappenerkrankung
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