Transcatheter tricuspid valve repair: Bringing the forgotten valve into the spotlight

Ailawadi and colleagues have provided an excellent summary of the spectrum of transcatheter devices for the treatment of tricuspid regurgitation (TR). Functional TR is the most common form of TR, and it remains largely asymptomatic until severe enough to cause right heart failure or congestive symptoms. Severe symptomatic TR will often not be treated surgically because of the associated high morbidity, in-hospital mortality, and poor long-term survival associated with open repair or replacement. Transcatheter approaches for the treatment of severe TR are ideal for those patients with severe, symptomatic TR, a high surgical risk, severe right ventricular dysfunction, or severe pulmonary hypertension. With the development of these new approaches, patients with multivalve disease can now be approached in a manner more similar to that for surgery, without leaving the pathology untreated. Although transcatheter solutions in the aortic and mitral realm have shown success, several factors have led to difficulties with transcatheter approaches for tricuspid valve disease. The complexity of the tricuspid valve anatomy such as its thinner leaflets, its elliptical annular shape, and, rarely, the presence of calcified structures has made the technology used for the aortic valve and mitral valve less reproducible for use with the tricuspid valve. Another important factor has been the difficulty with intraprocedural imaging guidance-the leaflets can be more difficult to see, grasping them can be difficult to accurately image, and shadowing from any mitral or aortic prostheses can significantly impair tricuspid valve visualization. Despite these limitations, several tricuspid valve-specific transcatheter solutions have been developed. As surgeons who have experience with tricuspid surgery, it is important that we remain engaged and lead in this area. The present summary details the variety of devices on the market used to treat TR percutaneously; they fall into 2 broad categories-those that aid in coaptation and those that replicate surgical annuloplasty.