What is tricuspid valve replacement with Evoque?

Transcatheter tricuspid valve replacement (TTVR) with the Evoque system (Edwards Lifesciences) is a minimally invasive technique to replace a severely leaking tricuspid valve without open heart surgery. The Evoque is a self-expanding bioprosthetic valve made of bovine pericardial leaflets mounted on a nitinol frame. It is delivered through a vein in the leg and deployed in the position of the native tricuspid valve.

How does it work?

The valve is delivered on a steerable catheter system through one of the femoral veins. Using a combination of x-ray and continuous transoesophageal echocardiogram (TOE) guidance, it is positioned across the native tricuspid valve. When deployed, the new valve seats within the native annulus, anchoring against the leaflets and chordae, and replaces the function of the leaking valve. After deployment we assess the valve carefully to confirm normal function and absence of significant leak around the implant.

Who is tricuspid valve replacement with Evoque recommended for?

Evoque tricuspid replacement is recommended for selected patients with symptomatic severe tricuspid regurgitation at increased risk for open heart surgery, in whom transcatheter edge-to-edge repair (TEER) is not the best option — typically because of complex valve anatomy, large gaps between the leaflets, severe leaflet tethering, or features that make a clip-based repair unlikely to reduce the leak sufficiently. As with TEER, the right ventricle and the rest of the heart need to be functioning well enough for the procedure to translate into clinical benefit. The TRISCEND II trial showed substantial reductions in tricuspid regurgitation and improvements in symptoms in carefully selected patients.

What is the process for deciding to treat someone with this technique?

Generally you would be referred by your GP or cardiologist. You would then be assessed in clinic by Dr Dawkins, which usually includes additional investigations — typically a transthoracic echocardiogram, a transoesophageal echocardiogram (TOE), and a cardiac CT scan to size the valve and plan the procedure. Once we have all the necessary information, we will discuss you at one of our regular structural valve meetings. These are attended by interventional cardiologists, cardiac surgeons, imaging experts and anaesthetists. If the consensus is that this would be a good treatment for you, and you would like to go ahead, we will offer you a procedure date.

What can I expect from the procedure?

The procedure is carried out under general anaesthetic with continuous TOE guidance. Vascular access is via the femoral vein. The procedure typically takes between two and three hours. Most patients stay in hospital for two to three nights afterwards. Dr Dawkins will see you in clinic a month or so after the procedure, but can be contacted in the interim if you have any queries or problems.

What are the benefits and risks?

Successful tricuspid replacement with Evoque substantially reduces the severity of regurgitation, which usually translates into improved breathlessness, less leg and abdominal swelling, and better exercise tolerance over the following weeks and months. As with any structural intervention there are risks, including bleeding from the access site, conduction problems (sometimes requiring a pacemaker), the need for further intervention, and rarely stroke or significant heart-related complications. We will discuss your individual risk profile in detail at your consultation, both verbally and in writing.

What experience does Dr Dawkins have?

Dr Dawkins is part of the structural heart programme at Cleveland Clinic London, which offers the full range of transcatheter tricuspid options, including Evoque tricuspid replacement. He has lectured on transcatheter tricuspid intervention at the British Heart Valve Society Annual Meeting and contributes to research and teaching on percutaneous tricuspid valve treatment.