Transcatheter pledget-assisted suture tricuspid annuloplasty (PASTA) to create a double-orifice valve

• Authors: Jaffar Khan, Emory University; Toby Rogers, National Heart, Lung, and Blood Institute; William H. Schenke, National Heart, Lung, and Blood Institute; Adam Greenbaum, Emory University; Vasilis Babaliaros, Emory University; Gaetano Paone, Emory University; Rajiv Ramasawmy, National Heart, Lung, and Blood Institute; Marcus Y. Chen, National Heart, Lung, and Blood Institute; Daniel A. Herzka, National Heart, Lung, and Blood Institute; Robert Lederman, Emory University
• Journal Title: Catheterization and Cardiovascular Interventions
• Volume: Volume 92, Number 3
• Publisher: Wiley: 12 months | 2018-09-01, Pages E175-E184
• Type of Work: Article | Post-print: After Peer Review
• Publisher DOI: http://doi.org/10.1002/ccd.27531
• Subjects: Health Sciences, Medicine and Surgery
• Keywords: Science & Technology; Life Sciences & Biomedicine; Cardiac & Cardiovascular Systems; Cardiovascular System & Cardiology; structural heart disease; transcatheter electrosurgery; tricuspid annuloplasty; tricuspid valve regurgitation; REGURGITATION; REPAIR; REPLACEMENT; MANAGEMENT; LEAFLET; DISEASE; SYSTEM; OUTCOMES; CLOSURE; ANNULUS

Abstract

Objectives: Pledget-assisted suture tricuspid valve annuloplasty (PASTA) is a novel technique using marketed equipment to deliver percutaneous trans-annular sutures to create a double-orifice tricuspid valve. Background: Tricuspid regurgitation is a malignant disease with high surgical mortality and no commercially available transcatheter solution in the US. Methods: Two iterations of PASTA were tested using trans-apical or trans-jugular access in swine. Catheters directed paired coronary guidewires to septal and lateral targets on the tricuspid annulus under fluoroscopic and echocardiographic guidance. Guidewires were electrified to traverse the annular targets and exchanged for pledgeted sutures. The sutures were drawn together and knotted, apposing septal and lateral targets, creating a double orifice tricuspid valve. Results: Twenty-two pigs underwent PASTA. Annular and chamber dimensions were reduced (annular area, 10.1 ± 0.8 cm2 to 3.8 ± 1.5 cm2 (naïve) and 13.1 ± 1.5 cm2 to 6.2 ± 1.0 cm2 (diseased); septal-lateral diameter, 3.9 ± 0.3 mm to 1.4 ± 0.6 mm (naïve) and 4.4 ± 0.4 mm to 1.7 ± 1.0 mm (diseased); and right ventricular end-diastolic volume, 94 ± 13 ml to 85 ± 14 ml (naïve) and 157 ± 25 ml to 143 ± 20 ml (diseased)). MRI derived tricuspid regurgitation fraction fell from 32 ± 12% to 4 ± 5%. Results were sustained at 30 days. Pledget pull-through force was five-fold higher (40.6 ± 11.7N vs 8.0 ± 2.6N, P <.01) using this strategy compared to single puncture techniques used to anchor current investigational devices. Serious complications were related to apical access. Conclusions: PASTA reduces annular dimensions and tricuspid regurgitation in pigs. It may be cautiously applied to selected patients with severe tricuspid regurgitation and no options. This is the first transcatheter procedure, to our knowledge, to deliver standard pledgeted sutures to repair cardiac pathology.