Transcatheter tricuspid valve replacement is quickly becoming a real option for patients with severe symptomatic TR, but the decision-making is still nuanced.

In this MurmurMD discussion, Dr. Aidan Raney speaks with Dr. Sameer Gafoor, about a Septuagenarian female with severe non-rheumatic tricuspid regurgitation, NYHA class III symptoms, prior mechanical mitral valve replacement, persistent AFib on warfarin, prior stroke, EF around 44%, RV dilation, moderately reduced RV function, TAPSE 1.1, and severe TR.

The case focuses on why Dr. Gafoor's team favored transcatheter tricuspid valve replacement over edge-to-edge repair, how they approached CT and echo sizing, and how they moved their program from TEE-guided TTVR toward ICE-only TTVR, including a pathway from general anesthesia with TEE and ICE to conscious sedation with ICE.

The discussion also covers key questions every TTVR program has to answer: surgical risk scoring, RV dysfunction, anticoagulation, pacemaker risk, working room, valve sizing, procedural imaging, fluid status matching, and what patients should expect after intervention.

KEY TOPICS

• Severe symptomatic non-rheumatic TR

• TTVR vs edge-to-edge repair decision-making

• Surgical risk vs tricuspid-specific risk scores

• RV dysfunction, TAPSE, and when to say no

• CT sizing vs TEE and ICE measurements

• Annular and basal RV oversizing

• Working room, RA height, RV height, and RV depth

• ICE-only TTVR workflow development

• Anchor position, commissures, and deployment assessment

• Matching fluid status between CT and procedure

• Anticoagulation requirements after TTVR

• Pacemaker risk and lifetime management questions

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CHAPTERS

00:00 – Introduction: TTVR case from Swedish Hospital

00:32 – Patient presentation: severe TR, AFib, MVR, stroke, and RV dysfunction

01:22 – Surgical consult, CT, TEE, and risk scoring

02:52 – Choosing intervention: repair vs replacement

03:52 – CT sizing, TEE discrepancy, and oversizing

04:53 – Working room: RA height, RV depth, and delivery space

05:35 – Moving from TEE-guided to ICE-only TTVR

07:54 – ICE setup, MPR views, and valve orientation

09:11 – Deployment assessment and anchor position

10:34 – Final result and key lessons learned

12:06 – Q&A: surgical risk scores and tricuspid-specific tools

13:56 – RV dysfunction and when to avoid TTVR

15:35 – Post-procedure support and Swan discussion

15:59 – ICE workflow as primary imaging strategy

17:28 – Closing thoughts

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