Two "firsts" in a case of tricuspid valve infective endocarditis following edge-to-edge repair

Ionut Alexandru Patrascu (Pforzheim)1, D. Binder (Pforzheim)1, W. Stähle (Pforzheim)1, F. Alfarwan (Pforzheim)1, K. Weinmann (Pforzheim)1, I. Ott (Pforzheim)1

1Helios Klinikum Pforzheim Medizinische Klinik I, Kardiologie Pforzheim, Deutschland


An 80-year-old man with symptomatic massive functional TR was referred for T-TEER by the Heart Team. The patient had undergone M-TEER 2x before, which eventually successfully treated mitral regurgitation, but had little to no effect on TR. His medical history included also permanent atrial fibrillation, stage 3B chronic kidney disease, arterial hypertension and peripheral artery disease. The patient complained of shortness of breath NYHA III, peripheral edema, and had a low KCCQ Score of 57.2 points and six minute walk distance (6MWD) of 250m. TTE confirmed massive TR: vena contracta 19mm, PISA 11mm, EROA 108mm2. Right heart cardiac remodeling was also present: RA 101.5 ml/m2 indexed volume, RV basal diameter 50mm, TV annulus 47mm, TAPSE 10mm. T-TEER addressed the main jet arising from the level of the antero-septal commissure, where 2 XT TriClipsTM were implanted, with TV bicuspidalization and TR reduction from massive to mild to moderate, while transvalvular gradient only rose to 1.5mmHg. The patient was extubated in the cath lab and discharged 3 days later. Thirty-day follow up showed persistent good result, with increased QoL (NYHA III to II, KCCQ-Score 57.2 to 77.5 points, 6MWD from 250 to 350m). RV systolic function (TAPSE 10 to 18mm, FAC 30 to 45%) improved and RA indexed volume decreased (101.5 to 84.7 ml/m2).  Unfortunately, five months later he was readmitted with recurrent syncope due to bradycardia below 40 beats per minute, on the basis of longstanding atrial fibrillation. He had no antiarrhythmic drugs. The indication for implantation of single chamber pacemaker was obvious, but concerns were raised due to the previous implanted TriClipsTM, both not to dislodge them nor to increase the transvalvular gradient.  For this reason PL insertion was performed under TEE guidance and a lateral course between the anterior and posterior leaflets was chosen. Fortunately, the lead did not interfere with the clips or residual TR, which in turn remained unchanged. No further increase in transvalvular gradient was seen and regular lead values were recorded. At that time, June 2021, this was the first reported case of PL implantation after T-TEER with the TriClipTM system. The patient remained oligosymptomatic for the following two years, until September 2023 he was readmitted with fever, productive cough and confusion, under the presumption of community-acquired pneumonia. Head-CT was negative, while chest X-ray showed no clear infiltrates. As his condition got worse under antibiotic therapy, TEE was ordered, which showed very good long-term result after 2x M-TEER, but worsened residual TR. More importantly, a mobile mass was present on the posterior TV leaflet on the atrial side, closer to the commissure than the centrally implanted clips. This irregular inhomogeneous structure of approx. 1.6cm length protruded through the TV and made contact with the more posterior placed clip, but not the PL. The IE suspicion was reinforced by positive blood cultures for Staphylococcus aureus. The patient went from slight initial confusion to severe mental impairment. A follow-up head-CT showed cerebellar ischemia, while on repeat-TEE the vegetation was not present any more, which raised the suspicion of cardioembolic stroke in the presence of TV endocarditis and residual atrial septal defect after 2x M-TEER. Despite our best efforts, the patient´s condition deteriorated and he died several days after. 

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