Simultaneous management of mitral and tricuspid regurgitation: the interventional "one-stop" approach
Atrial dilated cardiomyopathy (AdCM) frequently leads to annular dilatation, causing severe secondary mitral regurgitation (MR) and tricuspid regurgitation (TR). While conventional bivalvular surgery is an option, it remains associated with high morbi-mortality in fragile patients. The clinical challenge lies in the technical complexity of concomitant percutaneous repair, a strategy that is still poorly documented but potentially life-saving to avoid risks related to staged interventions or persistent hemodynamic instability.
This report presents the case of a 59-year-old female patient suffering from symptomatic heart failure refractory to optimal medical treatment. Presenting with massive MR and TR (grade 4+), her clinical profile was marked by a high surgical risk (STS score of 7.45%). Faced with this therapeutic impasse, the objective is to evaluate the feasibility of an unprecedented combined interventional procedure.
L'étude repose sur l'hypothèse qu'une intervention simultanée par Transcatheter Edge-to-Edge Repair (TEER) mitral et une annuloplastie tricuspide via le système innovant K-Clip™ peut restaurer la compétence valvulaire bivalvulaire. Cette approche vise à offrir une solution complète en une seule session, réduisant ainsi les risques liés aux anesthésies répétées et aux ponctions vasculaires multiples, tout en prévenant l'aggravation de la RT souvent observée après une intervention mitrale isolée.
Methodology and intervention protocol
This case report documents the management of a 59-year-old female patient (161 cm, 78 kg) presenting with atrial dilated cardiomyopathy complicated by severe (grade 4+) mitral regurgitation (MR) and tricuspid regurgitation (TR). Despite optimal medical treatment (Sacubitril/valsartan, metoprolol, spironolactone, vericiguat, dapagliflozin), heart failure persisted, with an STS score of 7.45%.
The interventional protocol, performed under echocardiographic and fluoroscopic guidance, combined two simultaneous techniques:
- Mitral TEER (M-TEER): Application of a "zipper" strategy using two short and wide clips (Dejin Hangzhou Medical). The first clip was deployed between segments A2 and A3, followed by a second between A2 and A1 to reduce residual MR.
- K-Clip™ Annuloplasty: 110-minute procedure using two devices (Shanghai Huihe Medical) to plicate the tricuspid annulus. The first clip (12 T, 36Fr) was anchored at 5:30 (posterior/septal junction) and the second (14 T, 42Fr) at 7:30 (anterior/posterior junction).
Coronary safety was ensured by a preoperative CT angiography (right coronary-to-annulus distance > 3.0 mm) and intraoperative angiography. Efficacy analysis was performed by immediate transesophageal echocardiography (TEE) and follow-up by transthoracic echocardiography (TTE) at one month.
Results of the simultaneous bivalvular intervention
The procedure combining mitral TEER and K-Clip™ tricuspid annuloplasty resulted in an immediate and significant reduction in regurgitation parameters. The K-Clip™ procedure lasted 110 minutes, without coronary complication.
Hemodynamic and structural evaluation
The following table summarizes the evolution of key echocardiographic parameters between the preoperative phase and the one-month follow-up:
| Parameter | Preoperative | Postoperative (1 month) |
|---|---|---|
| MR severity | Severe (4+) | Light (1+) |
| Severity IT (TR) | Severe (4+) | Light (1+) |
| EROA (IT) | 0.76 cm² | 0.18 cm² |
| Regurgitant volume (IT) | 120 mL | 28 mL |
| Diameter of the tricuspid valve annulus | 42.5 mm | 31 mm |
| Left Ventricular Ejection Fraction (LVEF) | 36 % | 45 % |
Intraoperative observations and safety
- Mitral Strategy: The implantation of two short and wide clips (Dejin Hangzhou Medical) using a "zipper" strategy (A2-A3 then A2-A1) reduced the MR from 4+ to 1+.
- Tricuspid Strategy: Two K-Clip™ devices (12T at 5:30 and 14T at 7:30) were deployed. The septo-lateral diameter of the annulus decreased from 43.1 mm to 32 mm.
- Coronary safety: Right coronary artery (RCA) angiography confirmed TIMI grade 3 flow after clip deployment, validating the absence of compression despite anatomical proximity.
Clinical follow-up
The patient was mobilized from the first postoperative day and discharged on D4. At the one-month follow-up, an improvement in cardiac remodeling was noted with a reduction in the diameter of the left atrium (from 58 mm to 54 mm) and the left ventricle (LVEDd from 66 mm to 63 mm). Heart failure symptoms disappeared, allowing for optimization of medical treatment (doubling the dose of Sacubitril/valsartan and metoprolol).
Clinical analysis and perspectives of the "one-stop" strategy
The results of this clinical case demonstrate the efficacy of synchronous percutaneous bivalvular correction. The immediate transition from massive regurgitation (4+) to a mild stage (1+) for both valves allowed for rapid symptomatic improvement and an increase in LVEF, from 36% to 45% at one month. Clinically, this approach avoids the documented risk of TR worsening after isolated mitral intervention, while reducing complications related to repeated anesthesia and multiple vascular punctures.
The use of the K-Clip™ system, an annuloplasty plication technology developed in China, highlights the importance of anatomical planning. Preoperative CT coronary angiography assessment is decisive here: a distance between the right coronary artery (RCA) and the tricuspid annulus of less than 3 mm constitutes a major risk of compression or occlusion during clamping. Although the treatment area is close to the atrioventricular node, no conduction complications were observed, validating the procedural safety under echocardiographic and fluoroscopic guidance.
However, the limitations of this study lie in its unique nature (n=1) and its short-term follow-up. While current data confirm that simultaneous treatment improves survival compared to isolated mitral intervention in patients with annular dilatation ≥ 40 mm, the long-term durability of this hybrid assembly requires larger cohorts to confirm these promising initial results.
In concrete terms, for the practitioner:
- Prioritize the "one-stop" approach: Treating both valves simultaneously during a single procedure reduces the risks associated with repeated anesthesia and prevents the worsening of tricuspid regurgitation often observed after isolated mitral repair.
- Secure the K-Clip™ annuloplasty: A preoperative CT scan analysis is imperative to measure the distance between the right coronary artery and the annulus; a threshold > 3 mm is required to rule out any risk of arterial compression or laceration.
- Adopt the "zipper" strategy: The use of multiple mitral clips allows for the progressive reduction of leaflet tension before finalizing the tricuspid annuloplasty, thus optimizing overall hemodynamic stability.
Source
- Original title: Concomitant transcatheter edge-to-edge treatment for mitral regurgitation and the K-Clip system for tricuspid regurgitation: one case report
- Authors: Cai He, H-M Guo, Wenwen Chen, W Wang
- Publication: Frontiers in Cardiovascular Medicine - 2026-06-08
- DOI: https://doi.org/10.3389/fcvm.2026.1791302
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