The landscape of tricuspid valve treatment is undergoing rapid transformation, prompting cardiac surgeons to reassess their role in this evolving field. At a packed session during the Society of Thoracic Surgeons (STS) annual meeting in Los Angeles, experts discussed the implications of recent innovations in transcatheter treatments and their impact on surgical practice.
Emergence of New Treatment Options
The FDA's recent approval of two groundbreaking devices has dramatically expanded the treatment landscape for tricuspid regurgitation (TR). The Evoque tricuspid valve replacement system, approved in February 2024, and Abbott's TriClip transcatheter edge-to-edge repair (TEER) device, approved in April 2024, represent significant advances in non-surgical interventions. Additional devices, including the Pascal and Cardioband TR, are currently under evaluation for potential U.S. market entry.
Dr. Vinod Thourani of Piedmont Heart Institute notes that while these transcatheter procedures show promising quality-of-life benefits, they have not demonstrated improved survival at one year. Long-term concerns regarding thrombosis, durability, and re-intervention remain significant considerations.
Surgical Outcomes Better Than Perceived
Challenging long-held beliefs about poor surgical outcomes, Dr. Michael Bowdish of Cedars-Sinai Medical Center presented encouraging data from recent studies. For isolated tricuspid valve surgery in patients without endocarditis, the overall operative mortality rate was 7.3%. More notably, patients with the lowest MELD scores demonstrated a remarkably low 30-day mortality rate of just 3.2%.
Professional Practice Implications
A proposed CMS National Coverage Determination for transcatheter tricuspid valve replacement has raised concerns among surgical specialists. Unlike TAVR protocols, the proposal doesn't require equal involvement of cardiac surgeons in determining patient suitability for procedures.
"The problem is what the cardiologists said about us, is that we don't show up, we don't see the patient," Dr. Thourani explained. "We've got to find a better pathway to be involved. If we don't, I promise you... we will get left behind."
European Experience and Future Outlook
Dr. Volkmar Falk from Deutsches Herzzentrum der Charité in Berlin shared insights from European practice, where transcatheter technologies have been available longer. He noted that while surgical approaches remain preferred for primary TR and concurrent left-sided valve disease, transcatheter treatments are becoming the standard for secondary TR in higher-risk patients.
The European experience also highlights potential challenges, with TEER procedures showing a 35% failure rate. These unsuccessful cases often require complex surgical management, presenting new challenges for surgeons.
Path Forward
Dr. Joseph Bavaria of Jefferson Health emphasized the significance of this transition period: "This is a massive issue for us right now." The development of tools like the STS Tricuspid Valve Surgery Risk Calculator demonstrates the field's evolution toward more precise patient selection and risk assessment.
As the field continues to evolve, experts stress the importance of maintaining a collaborative heart team approach, combining surgical expertise with innovative transcatheter technologies to optimize patient outcomes.
