With the U.S. Food and Drug Administration (FDA) approval of transcatheter tricuspid valve replacement (TTVR) and transcatheter edge-to-edge repair (T-TEER) procedures for tricuspid regurgitation treatment, heart specialists at the Washington University and Barnes-Jewish Heart & Vascular Center in St. Louis, Mo., are pioneering advances that enhance the quality of life for patients who have historically suffered debilitating symptoms with limited therapeutic options. Previously, treatments were primarily restricted to pharmacologic interventions, such as diuretics, or invasive approaches including open-heart surgery, which presented significant risk, particularly a heightened mortality rate among patients with tricuspid regurgitation. However, if left undertreated, severe tricuspid regurgitation may result in significant organ damage, culminating in conditions such as renal failure, hepatic dysfunction or right-sided heart failure.

The TTVR and T-TEER procedures represent significant innovations that not only improve patients’ quality of life but also reduce the degree of tricuspid regurgitation. Further, because these techniques are minimally invasive, they eliminate the requirement for cardiopulmonary bypass, as used in open-heart surgery, circumventing the complications often associated with more invasive surgical interventions and allowing for quicker recovery.

“Opening the chests of these patients and putting them on heart-lung machines to perform surgery really affects them,” says Tsuyoshi Kaneko, MD, a WashU Medicine surgeon, Chief of Cardiac Surgery at Barnes-Jewish Hospital, one of the few hospitals in the region to offer the techniques. “Avoiding that invasiveness is critical because if you go after a damaged heart, they're not going to do well with surgery.”

WashU Medicine specialists have been involved in clinical trials for both TTVR and T-TEER devices, being the only center in the area that participated in clinical trials evaluating both techniques.

How can TTVR and T-TEER treat tricuspid regurgitation?

Both TTVR and T-TEER are performed by accessing the femoral vein. The procedural guidance is primarily performed with intracardiac and transesophageal echocardiography.

During the TTVR procedure, a guidewire is advanced through the tricuspid valve into the right ventricle and is used as a railing system to deploy a self-expanding bioprosthetic valve, which anchors within the dysfunctional valve. In contrast, the T-TEER procedure involves grasping two of the three tricuspid leaflets with a clip to reduce regurgitant area. Generally, more than one clip is placed to minimize the amount of regurgitation.

During both procedures, the patient’s heart continues to function, obviating the need for cardiopulmonary bypass. “Also, during the procedure, patients are typically more stable because they don't have any changes in their blood pressure or heart rate,” Dr. Kaneko says.

Further, transcatheter-based procedures are significantly less invasive for the patient, resulting in quicker recovery times.

“After these transcatheter therapies, especially TTVR, a lot of these patients will go home the next day — that's how different the invasiveness is,” Dr. Kaneko says. “Patients recover so much faster, and I think that's probably the most significant impact.”

How do multidisciplinary expertise and early access to treatments impact patient care at the Washington University and Barnes-Jewish Heart & Vascular Center?

Since 2006, WashU Medicine specialists at Barnes-Jewish Hospital have been pioneers in transcatheter mitral valve interventions, accumulating substantial expertise that extends to treating tricuspid valve regurgitation.

Alan Zajarias, MD, a WashU Medicine interventional cardiologist at Barnes-Jewish Hospital, emphasizes that because WashU Medicine physicians have extensive experience with mitral valve procedures, they understand the full range of treatment options — and limitations — of each piece of technology. Because The Heart & Vascular Center has a full suite of treatments and tools, providers — including WashU Medicine cardiologists, interventional cardiologists, and cardiac surgeons with expertise in the latest catheter-based therapies — evaluate patients on their unique characteristics and make a recommendation based on clinical presentation and disease severity. This allows the team to treat patients, even if they have complex conditions.

In cases in which a patient is not a candidate for commercially approved devices, a clinical trial device or open surgery, the valve team can petition for compassionate use of a non-FDA-approved device.

“We’ve been successful when we ask for these permissions because we do this in an objective fashion,” Dr. Zajarias said.

Dr. Zajarias recalls cases in which a patient who had frequent hospital admissions for management of tricuspid regurgitation avoided hospitalization entirely three years post-procedure, greatly improving their quality of life and reducing health care expenses.

The Heart & Vascular Center is committed to the continuous advancement and refinement of these groundbreaking therapies, serving as a partner for patients referred for interventional assessment. In most cases, after treatment, patients will be able to return to the care of their cardiologist. “We see the patient, and we render an opinion on a therapy. We proceed, and we communicate with the referring physician immediately after the therapy is performed.”

Follow-up care includes visits at 30 days and one-year post-procedure, allowing patients who reside outside of the St. Louis region ample time to plan travel.

When should you refer patients?

The grading of tricuspid regurgitation has expanded from mild, moderate and severe to include massive and torrential severity, and the Heart & Vascular Center prefers to see patients when their tricuspid regurgitation is at least moderate or if there is a specific question regarding the disease process.  

If you would like to refer a patient experiencing tricuspid regurgitation for evaluation at the Heart and Vascular Center for TTVR or T-TEER procedures, call 314-286-1194. Your patient will benefit from:

• Highly skilled physicians and heart team: Our team is the region’s most experienced in valve repair and replacement procedures. Both cardiologists and cardiac surgeons participate in the heart team assessment to provide the best therapy tailored for the patients. You can have confidence that we thoroughly evaluate and recommend the most appropriate treatment for your patient. 
• Experience and advanced techniques: We have extensive experience in helping perfect new methods to correct valve problems. Since the early 2000s, we have participated in a large number of trials for new heart valve devices. With early access to innovative treatments, our team of WashU Medicine physicians provide care backed by extensive experience with the latest advancements, even for patients previously deemed unsuitable for surgery.
• Modern, well-equipped facilities: WashU Medicine physicians have access to the latest technology, with the capability to perform precise procedures. Your patient receives surgery in high-tech rooms where integrated systems enable physicians to see your patient’s imaging in real time while they work. 

Learn more about how to refer your patient to our Heart & Vascular Center.