Tricuspid TEER — Advanced Procedural Strategies-Dr. Pham Case slides

Dr. Pham Case slides

Pdf Summary

This case involves a 73-year-old woman with a history of pulmonary hypertension, heart failure with reduced ejection fraction (non-ischemic cardiomyopathy), status post cardiac resynchronization therapy with defibrillator (CRT-D) showing recovered EF of 55%, paroxysmal atrial fibrillation on warfarin, hypertension, and chronic kidney disease stage 3. She presented with NYHA class III symptoms, worsening lower extremity edema, and paroxysmal nocturnal dyspnea. Her medications included Lasix 40 mg daily, Coreg 12.5 mg twice daily, Aldactone 25 mg daily, and warfarin. Attempts to increase diuresis were limited due to worsening renal function.<br /><br />Initial evaluation showed a ventricular-paced rhythm at 60 bpm, blood pressure 150/90, serum creatinine 2.0, elevated NT-proBNP at 2200, and INR 2.2. Transthoracic echocardiogram revealed significant tricuspid regurgitation with large coaptation gaps of 11-12 mm. Right heart catheterization showed moderately elevated right atrial pressure and pulmonary artery pressures, with wedge pressure at 18 mmHg and modest cardiac output.<br /><br />Given the large coaptation gaps, the care team elected to admit the patient for "pre-habilitation," involving aggressive intravenous diuresis with high dose Lasix (80 mg IV twice daily) and low-dose milrinone infusion over five days, resulting in removal of approximately 10 liters of fluid and reduction of coaptation gaps to 2-3 mm.<br /><br />Following optimization, procedural transesophageal echocardiography confirmed suitability for transcatheter tricuspid edge-to-edge repair (T-TEER), with successful deployment of two XTW clips. At 30-day follow-up, the patient improved to NYHA class I-II with stable renal function and unchanged diuretic dose.<br /><br />The case emphasizes that large tricuspid valve coaptation gaps (>7 mm) necessitate volume optimization ("prehab") to improve leaflet coaptation, guided by screening right heart catheterization data. This approach can enable successful minimally invasive repair and improve clinical status without worsening renal function. Continuation of high-dose oral diuretics on discharge is recommended.

Keywords

pulmonary hypertension

heart failure with reduced ejection fraction

cardiac resynchronization therapy with defibrillator

paroxysmal atrial fibrillation

chronic kidney disease stage 3

tricuspid regurgitation

pre-habilitation with intravenous diuresis

transcatheter tricuspid edge-to-edge repair

right heart catheterization

NYHA functional class improvement