Transcatheter tricuspid valve annuloplasty for tricuspid regurgitation

Evidence-based recommendations on transcatheter tricuspid valve annuloplasty for tricuspid regurgitation in adults. This involves putting a device on the heart valve to help it close.

# Recommendations
For people with severe and symptomatic tricuspid regurgitation, evidence on the efficacy of transcatheter tricuspid valve annuloplasty is limited in quantity and quality. Evidence on its safety shows there are serious but well-recognised complications. Therefore, for these people, this procedure should only be used with special arrangements for clinical governance, consent, and audit or research. Find out what special arrangements mean on the NICE interventional procedures guidance page.
For people with mild or moderate tricuspid regurgitation, evidence on the safety and efficacy of transcatheter tricuspid valve annuloplasty is inadequate in quantity and quality. Therefore, for these people, this procedure should only be used in the context of research. Find out what only in research means on the NICE interventional procedures guidance page.
Clinicians wanting to do transcatheter tricuspid valve annuloplasty for people with severe and symptomatic tricuspid regurgitation should:
Inform the clinical governance leads in their healthcare organisation.
Give people (and their families and carers as appropriate) clear written information to support shared decision making, including NICE's information for the public.
Ensure that people (and their families and carers as appropriate) understand the procedure's safety and efficacy, and any uncertainties about these.
Audit and review clinical outcomes of everyone having the procedure. The main efficacy and safety outcomes identified in this guidance can be entered into NICE's interventional procedure outcomes audit tool (for use at local discretion).
Discuss the outcomes of the procedure during their annual appraisal to reflect, learn and improve.
Healthcare organisations should:
Ensure systems are in place that support clinicians to collect and report data on outcomes and safety for everyone having this procedure.
Regularly review data on outcomes and safety for this procedure.
The procedure should only be done in specialised centres with experience of the interventional management of tricuspid regurgitation. There should be immediate, onsite access to cardiac and vascular surgery.
Further research should include details of patient selection, including the type and severity of tricuspid regurgitation.# The condition, current treatments and procedure

# The condition
Tricuspid regurgitation is when blood flows backwards through the tricuspid valve because it does not close properly during systole. It can be caused by a problem with the valve itself (primary). But it is more commonly secondary to an underlying cardiac problem that has caused the heart to become dilated.
People with mild tricuspid regurgitation do not usually have any symptoms. If the regurgitation is severe people may have fatigue and weakness, active pulsing in the neck veins, liver enlargement, ascites, peripheral oedema and renal impairment. Pulmonary hypertension may develop.

# Current treatments
Treatment may not be needed if there are no or mild symptoms. There are no specific medicines for treating tricuspid regurgitation itself, but symptoms of heart failure are managed with diuretics and other medicines. Medication to reduce pulmonary artery pressure or pulmonary vascular resistance, or both, is used for severe functional tricuspid regurgitation and severe pulmonary hypertension.
People with severe symptoms may have surgery to repair or replace the tricuspid valve. Isolated tricuspid valve surgery is rarely done because it is associated with high morbidity and mortality. More commonly, it is done at the same time as surgery to the valves on the left side of the heart (mitral and aortic).

# The procedure
Transcatheter tricuspid valve annuloplasty is designed to improve the function of the tricuspid valve with less morbidity and mortality than conventional surgical annuloplasty. It has been proposed as an option for people in whom conventional open surgery poses a high risk. The procedure aims to reduce regurgitation, increase quality of life, reduce hospital admissions related to heart failure and improve survival.
The procedure is done under general anaesthesia using transoesophageal echocardiography and fluoroscopy guidance. Access to the heart is through the femoral or jugular vein.
Different systems have been used and details of the technique vary. In one example, an annuloplasty ring or band is delivered through a catheter and implanted around the circumference, or annulus, of the tricuspid valve. A size adjustment tool is used to contract the device, which reduces the tricuspid annular diameter and brings the valve leaflets together. When the appropriate amount of reduction has been achieved, the implant is detached from the delivery system, which is then removed. In other systems, sutures are used to either exclude the posterior leaflet and create a functional bicuspid valve or to reduce the area of the tricuspid annulus. Adequate reduction of tricuspid regurgitation is assessed using echocardiography.