European Heart Journal Advance Access published online on November 18, 2009
European Heart Journal, doi:10.1093/eurheartj/ehp474
Percutaneous caval stent valve implantation: investigation of an interventional approach for treatment of tricuspid regurgitation
1 Department of Internal Medicine I (Cardiology, Angiology, Pneumology), Friedrich-Schiller University, Jena, Germany
2 Institute of Laboratory Animals Science, Jena, Germany
Received 30 July 2009; revised 15 September 2009; accepted 8 October 2009 * Corresponding author. Tel: +49 3641 932 4518, Fax: +49 3641 932 4102, Email: alexander.lauten{at}med.uni-jena.de
Aims: Severe tricuspid regurgitation (TR) reduces cardiac output (CO) and increases central venous pressure leading to secondary organ dysfunction. To date, the open surgical approach is the only option to treat TR. Herein, we report our experience of treatment by percutaneous implantation of valved stents in the inferior vena cava (IVC) and superior vena cava (SVC) to substitute tricuspid valve function in a model of acute insufficiency.
Methods and results: Acute TR grades III–IV was created in 13 sheep (54–75 kg) via papillary muscle and chordae avulsion using a 0.07 inch wire blade. Successful creation of TR was confirmed using angiography and by a prominent ventricular wave in central venous pressure recording. Two self-expanding nitinol stents containing a porcine pulmonary valve were then implanted in the IVC and SVC in a transcatheter approach. Implantation was performed through the right jugular vein by means of a 21 F catheter and guided by fluoroscopy. Haemodynamics were continuously monitored and valve function was verified by angiography and epicardial echocardiography. After successful implantation and proof of concept in the acute study (acute group, n = 9), chronic studies were (n = 4, 4 weeks follow-up) performed. Tricuspid regurgitation grades III–IV was successfully created in all animals and resulted in a significant reduction of CO. A ventricular wave in the IVC of 16.2 ± 2.33 mmHg (acute group) and 14.9 ± 1.71 mmHg (chronic group) confirmed the presence of severe TR. After deployment of the IVC and the SVC valve, the ventricular wave in the IVC significantly decreased to 13.9 ± 2.97 mmHg (acute group) and 12.7 ± 1.15 (chronic group), whereas CO significantly increased to 4.20 ± 0.84 L/min (acute group) and 5.4 ± 0.67 L/min (chronic group). At autopsy, correct device position was verified in all successfully implanted animals, no macroscopic damage resulting from the implantation procedure was observed.
Conclusion: In high-grade tricuspid insufficiency, percutaneous implantation of valved stents in the central venous position reduces venous regurgitation and improves haemodynamics in the animal experiment. Implantation of one or two valves in central venous position is technically feasible. Functional replacement of the insufficient tricuspid valve leads to an increase in CO. This technique expands the potential therapeutic options for patients with relevant tricuspid valve regurgitation having a high risk for open heart surgery.
Key Words: Tricuspid regurgitation • Transcatheter valve implantation • Percutaneous tricuspid valve replacement • Stent valve