Indications for Tricuspid Clip
Transcatheter tricuspid valve repair using the tricuspid clip may be considered in patients with symptomatic severe secondary tricuspid regurgitation who are deemed inoperable or at high surgical risk by a heart valve team. 1
Patient Selection Criteria
Primary Indications
- Severe symptomatic secondary tricuspid regurgitation (TR) despite optimal medical therapy
- Patients considered inoperable or at high surgical risk for conventional surgery
- Treatment at specialized heart valve centers with expertise in tricuspid valve disease
Clinical Factors Supporting Intervention
- Persistent symptoms of right-sided heart failure despite guideline-directed medical therapy
- Recurrent hospitalizations for right heart failure
- Progressive right ventricular dilatation or dysfunction
- Absence of severe right ventricular or left ventricular dysfunction
- Absence of severe pulmonary vascular disease/hypertension
Anatomical Considerations
- Suitable valve anatomy for clip placement
- Central or anteroseptal jet location preferred
- Adequate leaflet tissue for grasping
- Absence of severe leaflet tethering (tethering height >8 mm may predict poor outcomes)
Contraindications
- Severe right ventricular dysfunction
- Severe irreversible pulmonary hypertension
- Advanced liver dysfunction or cirrhosis
- Primary tricuspid valve disease with significant structural abnormalities
- Active endocarditis
Evidence Base and Guideline Recommendations
The 2017 ESC/EACTS guidelines state that "percutaneous repair techniques are in their infancy and must be further evaluated before any recommendations can be made" 1. However, more recent guidelines (2022) indicate that "transcatheter treatment of symptomatic secondary severe TR may be considered in inoperable patients at a heart valve centre with expertise in the treatment of TV disease" (Class IIb, Level C) 1.
Clinical data from the TRILUMINATE trial demonstrated that at 1 year, the TriClip device:
- Reduced TR to moderate or less in 71% of subjects
- Improved NYHA functional class (83% in class I/II vs 31% at baseline)
- Improved 6-minute walk distance
- Showed significant reverse right ventricular remodeling
- Had low major adverse event rate (7.1%) 2
Procedural Approach
The procedure is performed under general anesthesia with transesophageal echocardiographic and fluoroscopic guidance. The tricuspid clip is delivered via a transfemoral venous approach using a dedicated steerable guide catheter. The edge-to-edge repair technique typically targets the anteroseptal or anteroposterior commissures to create a bicuspidization effect 3, 4.
Important Caveats
- Patient selection should be performed by a multidisciplinary heart team
- Echocardiographic assessment by an experienced core laboratory is crucial for proper patient selection
- The procedure should only be performed at centers with expertise in transcatheter valve interventions
- Long-term durability data beyond 1 year is still limited
- Surgical options should be considered first in appropriate surgical candidates
While the tricuspid clip shows promising results for reducing TR and improving symptoms, it should be recognized that this technology is still evolving, and patient selection remains critical to achieving optimal outcomes.