Author + information
- Received September 25, 2016
- Revision received October 7, 2016
- Accepted October 20, 2016
- Published online February 1, 2017.
- Robert Schueler, MD∗ (, )
- Christoph Hammerstingl, MD,
- Nikos Werner, MD and
- Georg Nickenig, MD
- ↵∗Address for correspondence:
Dr. Robert Schueler, Medizinische Klinik und Poliklinik II, Universitätsklinikum Bonn, Sigmund-Freud-Straße 25, Bonn 53105, Germany.
A 75-year-old man (European System for Cardiac Operative Risk Evaluation II 6.34%) presented with aggravating dyspnea New York Heart Association functional class III, edema, and fatigue despite best medical treatment. Three-dimensional transoesophageal echocardiography (TEE) showed massive tricuspid regurgitation (TR) (proximal isovelocity surface area 2.5 cm, vena contracta width 1.8 cm, effective regurgitant orifice area 0.8 cm2, regurgitant volume 160 ml/beat, coaptation defect gap 2.7 cm, coaptation defect area 1.8 cm2), and annular dilation (septolateral diameter 52 mm, anteroposterior diameter 38 mm) due to right ventricular and right atrial enlargement (right atrial area 70 cm2) despite a good left ventricular function (left ventricular ejection fraction 55%) (Figures 1A and 1B, Online Video 1).
Following Heart Team decision edge-to-edge repair was tried but failed, due to missing coaptation. Direct annuloplasty with the Cardioband device (Valtech Cardio, Or Yehuda, Israel) was therefore planned.
The 25-F steerable Cardioband sheath was introduced over a super-stiff guidewire (Amplatzer, Boston Scientific, Marlborough, Massachusetts) into the right atrium via the right femoral vein and the inferior vena cava. Thereafter, the implant delivery system, consisting of the steerable guide catheter and the implant catheter with the Cardioband implant mounted on its distal end, is brought forward. For orientation and safety reasons a coronary wire was placed in the right coronary artery, which marks the tricuspid annulus, especially at the anterior and lateral region.
Implantation of the Cardioband was started from the aortic side around the anterior annulus to the posterior tricuspid annulus at the ostium of the coronary sinus. The procedure was guided by fluoroscopy and 3-dimensional TEE (Figures 1C and 1D, Online Videos 2, 4, and 5).
After implantation of 17 stainless steel anchors (6 mm long) and cinching of the Cardioband device of about 5 cm tricuspid annular dimensions were relevantly reduced (septolateral diameter to 31 mm [40%], anteroposterior diameter to 27 mm [28%]), and TR was downgraded from massive to moderate (proximal isovelocity surface area 0.7 cm, vena contracta width 0.6 cm, effective regurgitant orifice area 0.2 cm2, regurgitant volume 45 ml/beat) (Figures 1E and 1F, Online Video 3). TEE demonstrated restoration (Online Video 5) of sufficient coaptation of tricuspid leaflets. Invasively determined right atrial pressure was reduced from 28 mm Hg before to 20 mm Hg after cinching. No complications occurred and the patient was discharged on day 5 post-procedure in New York Heart Association functional class I to II. Of note, transthoracic echocardiography before discharge showed mild-to-moderate TR and a decrease in vena cava inferior diameters (pre-procedure 31 mm, post-procedure 25 mm).
Interventional annuloplasty using the Cardioband system might be an efficient future option for patients with symptomatic TR and dilated right ventricular dimensions. Further research has to prove durability and safety of the procedure as well as long-term clinical effects.
For supplemental videos and their legend, please see the online version of this article.
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received September 25, 2016.
- Revision received October 7, 2016.
- Accepted October 20, 2016.
- American College of Cardiology Foundation