Author + information
- Received July 24, 2018
- Revision received August 13, 2018
- Accepted September 11, 2018
- Published online December 17, 2018.
- Livia Gheorghe, MDa,
- Martin Swaans, MD, PhDa,
- Paolo Denti, MD, PhDb,
- Bernard Rensing, MD, PhDa and
- Jan Van der Heyden, MD, PhDc,∗ ()
- aInterventional Cardiology Unit, St. Antonius Hospital, Nieuwegein, the Netherlands
- bCardiac Surgery, San Raffaele University Hospital, Milan, Italy
- cInterventional Cardiology Unit, AZ Sint-Jan Hospital, Brugge, Belgium
- ↵∗Address for correspondence:
Dr. Jan Van der Heyden, Interventional Cardiology Unit, AZ Sint-Jan Hospital, Ruddershove 10, 8000 Brugge, Belgium.
- controlled pneumopericardium
- percutaneous annuloplasty
- percutaneous tricuspid valve repair
- tricuspid regurgitation
The 4Tech TriCinch Coil System (4Tech Cardio, Galway, Ireland) is a novel percutaneous device for severe functional tricuspid regurgitation (TR) designed to reduce tricuspid annular dimensions.
During the development of the TriCinch Coil System, optimization of the anchoring system and its implantation were obtained. The anchor is placed in the pericardial space to ensure better stability of the device (Figure 1). During device implantation, expansion and visualization of the pericardial space is needed. A simple and safe way to achieve visibility in the pericardial space is obtained by creating controlled pneumopericardium using CO2 (1,2).
An 81-year-old woman with isolated significant functional TR (grade 4+) (Figures 2A and 2B) was referred to our center to discuss treatment options. She was highly symptomatic (functional class III). Because of comorbidities and frailty, the patient was referred for percutaneous tricuspid procedure with the TriCinch Coil device, under general anesthesia.
To create pneumopericardium, the right atrial appendage was punctured (via the femoral vein) with the backside of a 0.014-inch wire using a multipurpose catheter and a microcatheter (telescopic technique). The latter was placed in the pericardial space (Figures 3A and 3B). The right coronary artery was wired (Figure 3C). Up to 300 ml CO2 was injected into pericardial space through the microcatheter, without significant impact on hemodynamic status (Figure 3D, black arrows, Online Video 1). The delivery system was then advanced through the inferior vena cava into the right atrium and steered toward the anterior-posterior region of the tricuspid valve annulus. Once the target zone was reached at the hinge point of the leaflet determined on intracardiac and transesophageal echocardiography, fluoroscopically controlled transmural needle puncture was performed, and the coil was deployed in the pericardial space (Online Video 2, Figure 3E). Finally, the whole system was tensioned to remodel the tricuspid valve by reducing the annular dimension and reducing TR. The tension was maintained using a 27-mm nitinol stent deployed in the inferior vena cava (Figure 3F).
At 1 month, computed tomography depicted the TriCinch Coil system in the index position (Figure 3G).
We report the first-in-human case of percutaneous tricuspid annuloplasty using the TriCinch Coil System with intentional creation of pneumopericardium to ensure correct advancing of the device through the myocardium to the pericardial space. This new technique allows safe and controlled deployment of the device, ensuring sustained stability at follow-up.
Drs. Denti and Van der Heyden are consultants for 4Tech Cardio. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received July 24, 2018.
- Revision received August 13, 2018.
- Accepted September 11, 2018.
- 2018 American College of Cardiology Foundation