Author + information
- Received November 7, 2016
- Revision received December 19, 2016
- Accepted December 29, 2016
- Published online March 20, 2017.
- Azeem Latib, MDa,b,∗ (, )
- Antonio Mangieri, MDa,
- Luca Vicentini, Enga,
- Luca Ferri, MDa,
- Matteo Montorfano, MDa,
- Gennaro Ismeno, MDc,
- Damiano Regazzoli, MDa,
- Marco B. Ancona, MDa,
- Manuela Giglio, MDa,
- Paolo Denti, MDa,
- Antonio Colombo, MDa,b and
- Eustachio Agricola, MDa
- aSan Raffaele Scientific Institute, Milan, Italy
- bEMO-GVM Centro Cuore Columbus, Milan, Italy
- cAzienda Ospedaliera Sant’ Anna e San Sebastiano, Caserta, Italy
- ↵∗Address for correspondence:
Dr. Azeem Latib, Interventional Cardiology Unit, San Raffaele Scientific Institute and EMO GVM Columbus, Via Olgettina 58, Milan 20132, Italy.
- multislice computer tomography
- percutaneous tricuspid valve annuloplasty
- transesophageal echocardiography
- tricuspid regurgitation
A 74-year-old woman with severe functional tricuspid regurgitation (FTR) was admitted with New York Heart Association functional class III with signs of right-sided heart failure.
She had a medical history of hepatitis B–related liver disease, permanent atrial fibrillation, and previous stenting on right coronary and circumflex arteries. The patient was screened using multislice computed tomography (MSCT) and transthoracic echocardiography (TTE) that confirmed severe FTR (Figure 1A, Online Video 1) secondary to annular dilatation (Figure 1C) with coexisting right ventricular dysfunction with a systolic pulmonary artery pressure of 65 mm Hg. Transesophageal echocardiography (TEE) was contraindicated because of a large esophageal diverticulum.
After heart team discussion, the patient was scheduled for percutaneous annuloplasty using the TriCinch system (4Tech Cardio Ltd., Galway, Ireland) (1). MSCT confirmed the feasibility of the safe anchoring area at the level of the anterior leaflet (Figure 1A). The procedure was performed under conscious sedation using intracardiac echocardiography, TTE, and fluoroscopic guidance. A 24-F GORE DrySeal Sheath (Gore Medical, Flagstaff, Arizona) was inserted in the right femoral vein for insertion of the steerable TriCinch delivery system into the right atrium. The anchor was inserted on the anterior part of the annulus, then coupled to the inferior vena cava stent via a Dacron band, which was implanted by tensioning the annulus and reducing the anteroseptal diameter (Figures 1D and 1E). Despite the lack of TEE monitoring, the procedure was performed without complication. Pre-discharge TTE confirmed the good procedural result with residual mild tricuspid regurgitation (Figure 1F, Online Video 2) and immediate clinical improvement.
We report the first-ever case of percutaneous tricuspid annuloplasty under conscious sedation and without TEE monitoring. The feasibility of this approach was possible due to meticulous pre-procedural assessment with MSCT and TTE, which identified the target zone of the anchor. The use of conscious sedation instead of general anesthesia reduces the risk of periprocedural complications and improves post-procedural recovery in this high-risk group of patients with FTR.
For supplemental videos and their legends, please see the online version of this article.
Dr. Latib has served as a consultant for 4Tech, Mitralign, Millipede, and Valtech Cardio; and has received speaking honoraria from Abbott Vascular. Dr. Denti has served as a proctor for 4Tech; and as a consultant to 4Tech, Valtech Cardio, Abbott Vascular, and Innovheart. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received November 7, 2016.
- Revision received December 19, 2016.
- Accepted December 29, 2016.
- 2017 American College of Cardiology Foundation