First case in Southwest China! TTVA + TEER | The First People's Hospital of Yunnan Province successfully performed a one-stop procedure using two domestic devices

Patient Basic Information

Gender: Female, Age: 67 years old

The patient was admitted due to recurrent dyspnea and intermittent bilateral lower limb edema. Past medical history: The patient has had hypertension for many years with irregular medication use. She was diagnosed with cerebral infarction two years ago presenting with facial deviation. Recurrent unexplained vaginal bleeding has occurred over the past month, and gynecological surgery is scheduled. Electrocardiogram revealed persistent atrial fibrillation. Post-admission echocardiography showed marked bilateral atrial enlargement, moderate to severe mitral regurgitation and severe tricuspid regurgitation.

Preoperative Evaluation of the Mitral Valve

Severe mitral insufficiency (MR 4+), functional mitral regurgitation (FMR). Regurgitation is mainly originated from segment 2 with central regurgitant jet. During systole, the anterior and posterior mitral leaflets are nearly at the annular plane, with a low leaflet-to-annulus index. Interatrial septum presents with paradoxical motion and significant mitral annular dilatation is noted.

Preoperative Evaluation of the Tricuspid Valve

Intraoperative transesophageal echocardiography (TEE) assessment before procedure: Severe tricuspid regurgitation (4+), with a mean vena contracta width of 9 mm. Regurgitant orifices are located at the anteroseptal, central and posteroseptal regions. A 4 mm gap is detected at the central portion. Marked tricuspid annular dilatation is present with a mean annular diameter of 47 mm. The patient has persistent atrial fibrillation.

Preoperative CT assessment: Systolic circumference: 143 mm, area: 1608 mm². Non-right dominant coronary circulation. The coronary course at the anteroposterior junction aligns with the valvular annulus, while the remaining segments course toward the atrium, which may pose potential procedural impacts.

Surgical Strategy

1.First, perform transcatheter mitral edge-to-edge repair (DragonFly™-TEER). The interatrial septum of the patient may have poor support, leading to height loss after transseptal puncture. Therefore, a sufficient puncture height (>4.5 cm) is required. Given the significant mitral annular dilatation, attention should be paid to leaflet tension during clip closure to reduce the risk of leaflet injury. One XW0612 clip was deployed at segment 2. Additional clip placement was determined intraoperatively based on residual regurgitation and transvalvular pressure gradient. Specifically, one 0612 clip was implanted at segment 2, and one 0609 clip was deployed laterally if necessary. After clip deployment, regurgitation was reduced to mild to moderate, with the mean transvalvular pressure gradient below 5 mmHg. Upon completion of TEER and confirmation of stable hemodynamics, transcatheter tricuspid valve annuloplasty with K-Clip^® was subsequently performed via the internal jugular vein approach.

2. After conducting multi-dimensional assessments of the tricuspid annulus and the distance between the right coronary artery and the annulus, we formulated a precise treatment plan centered on implantation of three K-Clip^® devices, taking full account of the patient's lesion characteristics, anatomical details and coronary artery-related influencing factors. During the procedure, a 14T K-Clip^® was implanted at the posteroseptal junction of the tricuspid valve, a 12T K-Clip^® was deployed on the posterior leaflet, and another 14T K-Clip^® was placed at the anteroposterior junction of the tricuspid valve. This three-point positioning implantation technique can effectively reduce the tricuspid annular diameter and improve leaflet coaptation, directly correcting tricuspid regurgitation anatomically and providing crucial structural support for the patient's smooth postoperative recovery.