Tricuspid Valve Repair with MitraClip

Name the cardiac device. • Xray of the Week

Figure 1. Figure 1. AP Chest X-ray demonstrating placement of 3 MitraClips over the tricuspid valve.

Figure 2. A: AP chest X-ray demonstrating placement of 3 MitraClips over the tricuspid valve (yellow arrow)

B: Coronal chest CT showing 3 MitraClips over the tricuspid valve in the right atrioventricular septum (red arrow). Mild right atrial dilation is noted.

C: Axial chest CT showing 3 MitraClips over the tricuspid valve in the right atrioventricular septum (orange arrow). A normal mitral valve is seen (green arrow). The right atrium is mildly dilated.

Discussion:

An echocardiogram is the gold standard for evaluating and determining the severity of tricuspid regurgitation (TR)[2]. Severity ranges from mild, moderate, to severe using both qualitative (valve morphology) or quantitative measures (flow calculations and distention of chambers) [2]. The leading cause of TR is due to left heart failure. Rarer causes include rheumatic disease, congenital, myxomatous degeneration, endocarditis, or pulmonary hypertension [3]. Treatment can vary from clinical monitoring, pharmacological therapy, or surgery, depending on the severity and clinical symptoms [4]. Current surgical techniques include tricuspid annuloplasty and tricuspid valve repair. However, minimally invasive methods are starting to gain popularity as the mainstay of treatment. These minimally invasive procedures include heterotopic caval transcatheter valve implantation, transcatheter tricuspid valve annuloplasty, and tricuspid clip placement (MitraClip) [4,5].

Tricuspid clip placement is a unique and innovative procedure; the idea stems from a repair method for regurgitant mitral valves. Pre-procedure planning includes an echocardiogram with a 3D rendering of the tricuspid valve (TV) to increase clip placement accuracy [5]. The procedure first begins with gaining femoral/jugular vein access and inserting a stiff guidewire into the right atrium, confirmed with fluoroscopy [5,6]. A 24 French catheter is advanced over the guidewire. The clip is then inserted through the catheter and positioned perpendicular to the tricuspid valve using 3D rendering of the TV via echocardiogram [6]. An intra-operative echocardiogram is done to measure the change in regurgitation associated with clip placement to optimize reduction. Clips are then placed around the TV leading to an “edge-to-edge” repair [5]. Patients who underwent the procedure showed improvement in the severity of TR and associated symptoms [5,6]. Figures 1 and 2 show tricuspid clip placement.

References:

1. Nina VJ, Silva NA, Gaspar SF, et al. Atypical size and location of a right atrial myxoma: a case report. J Med Case Rep. 2012;6:26. Published 2012 Jan 23. doi:10.1186/1752-1947-6-26

2. Arsalan M, Walther T, Smith RL 2nd, Grayburn PA. Tricuspid regurgitation diagnosis and treatment. Eur Heart J. 2017;38(9):634-638. doi:10.1093/eurheartj/ehv487

3. Rogers JH, Bolling SF. The tricuspid valve: current perspective and evolving management of tricuspid regurgitation. Circulation. 2009;119(20):2718-2725. doi:10.1161/CIRCULATIONAHA.108.842773

4. Rodés-Cabau J, Taramasso M, O'Gara PT. Diagnosis and treatment of tricuspid valve disease: current and future perspectives. Lancet. 2016;388(10058):2431-2442. doi:10.1016/S0140-6736(16)00740-6

5. Hammerstingl C, Schueler R, Malasa M, Werner N, Nickenig G. Transcatheter treatment of severe tricuspid regurgitation with the MitraClip system. Eur Heart J. 2016;37(10):849-853 doi:10.1093/eurheartj/ehv710

6. Schofer J, Tiburtius C, Hammerstingl C, et al. Transfemoral Tricuspid Valve Repair Using a Percutaneous Mitral Valve Repair System. J Am Coll Cardiol. 2016;67(7):889-890. doi:10.1016/j.jacc.2015.11.047

Deven Champaneri is a medical student at Edward Via College Osteopathic Medicine (VCOM) – Carolinas and plans to pursue residency in diagnostic radiology. While he was rotating through various specialties, he realized his passion for DR and valued its role in all aspects of medicine. He graduated from the University of South Carolina in 2017 with a degree in Business Marketing. During his undergraduate studies, he was involved with multiple volunteer organizations, such as Camp Kemo a summer camp for children with cancer and Palmetto Richland Children’s Hospital. Currently, he mentors at-risk high-school students and tutors students for Step 1/COMLEX 1. In his spare time he enjoys, golfing, backpacking, cooking, and spending time with family.

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Kevin M. Rice, MD is the president of Global Radiology CME

Dr. Rice is a radiologist with Renaissance Imaging Medical Associates and is currently the Vice Chief of Staff at Valley Presbyterian Hospital in Los Angeles, California. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015, Dr. Rice and Natalie Rice founded Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" Award for the Most Effective Radiology Educator.

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