Remodelling of the tricuspid annulus by T-TEER – a 3D echoardiography study

Background: Transcatheter edge-to-edge repair of the tricuspid valve (T-TEER) has developed in into a widely adopted therapeutic option in symptomatic patients with severe tricuspid regurgitation (TR) who are at high risk for surgery. TEER of the mitral valve has been found to be associated with significant changes of mitral annulus’ geometry. With this study we sought to assess the impact of T-TEER on the annulus of the tricuspid valve using three-dimensional (3D), periprocedural echocardiography (TEE).  

Methods: For this retrospective single-centre registry we screened all consecutive patients who underwent T-TEER between January of 2022 until October 2024. For analysis of annular remodeling, we included all patients for whom 3D-TEE volumes of the complete tricuspid annulus were available before and after intervention. All 3D-datasets were recorded from either mid- or deep transesophageal views, using a Philips EPIQ CVxi system. For image analyses we used IntelliSpace Cardiovascular (Version 3.2) and QLAB (Version 11.1; both Philips, The Netherlands). For all patients septolateral (s/l), anteroposterior (a/p) diameters, perimeter and the projected annular area were analyzed in endsystolic and enddiastolic frames. Preemptively, TR was evaluated by transthoracic and transoesophageal echocardiography and was categorized into five grades according to the proposed classification of Hahn et al. and based on the ESC and ACC guidelines.  

Results: We included 42 patients in our study, the mean age was 83 years (IQR: 85), 64% were female. 25% of the patients were NYHA functional class II, 60% functional class III or and 15% class IV. 50 percent of the patients were treated using the PASCAL systems (Edwards Lifesciences, USA), 50 % were treated with the TriClip system (Abbott Medical, USA). In 81% of the patients two or more devices were used. There was a significant reduction in systolic (3,61 ± p, p< 0.01) and diastolic (p< 0.01) diameters, in systolic (1.1 ± 2.6 cm2, p= 0.01) and diastolic (0.14 ± 3.3 cm2, p= 0.01) 3D area. There was no significant change in a/p diameter. There was no preprocedural difference in TR grade between device type but there was a significant (p< 0.01) lower TR grade in patients who received a Triclip XTW. Annuloplastic effect regarding area change was significantly more present in Triclip XTW.

Conclusion: 3D-TEE based analysis of the tricuspid annulus detected a significant annuloplastic effect by T-TEER. As expected, there was a reduction in TV area and s/l diameter. There was no significant change in a/p diameter. Further investigations in larger collectives are required to validate these findings and test for potential association of the documented annuloplastic effect with TR reduction and clinical outcome.