Team Led by Director Li Peng from Ulanqab Central Hospital, Inner Mongolia Skillfully Uses K‑Clip® to Treat a Patient with Severe Tricuspid Regurgitation Following Double‑Valve Replacement
Recently, the team led by Chief Physician Li Peng from the Department of Cardiothoracic Surgery at Ulanqab Central Hospital in Inner Mongolia successfully performed minimally‑invasive interventional therapy using the K‑Clip® Transcatheter Tricuspid Annuloplasty System for a patient with severe functional tricuspid regurgitation following combined mitral and aortic mechanical valve replacement. In this case, ultrasonic artifacts generated by the two mechanical prosthetic valves severely interfered with imaging visualization of the tricuspid valve region. Relying on profound understanding of tricuspid valve anatomy and flexible switching among multi‑plane ultrasound views, the team gave full play to the unique advantages of K‑Clip® in focused annular assessment. While mechanical‑valve artifacts mainly obscure leaflet structures, the K‑Clip anchors at the annulus and is less affected by artifacts. The operation was completed precisely, opening up a safe and efficient new minimally‑invasive therapeutic pathway for high‑surgical‑risk patients with severe valvular heart disease.
The patient had previously undergone combined aortic and mitral mechanical valve replacement. After standardized conservative medical treatment including diuresis before the procedure, the therapeutic effect was unsatisfactory and symptoms kept recurring. Post‑admission cardiac examinations revealed marked biatrial enlargement with normally functioning prosthetic aortic and mitral valves. Severe functional tricuspid regurgitation was confirmed with a substantially increased leaflet coaptation gap, and progression of the disease could hardly be controlled by conventional medical therapy.
Metallic echoes produced by the two intracorporeal mechanical valves created extensive imaging artifacts under transesophageal echocardiography, heavily obscuring tricuspid anatomical structures and greatly increasing the difficulty of pre‑procedural strategy formulation and intra‑procedural precise manipulation. Before surgery, Dr. Li Peng’s team held multiple case discussions, formulated a dedicated K‑Clip procedural plan for dual‑anchor implantation, repeatedly simulated the procedure with multi‑plane transesophageal echocardiography, pre‑planned artifact‑avoidance trajectories, and built a solid safety barrier for the whole operation.
Patient Profile
The patient was a 73‑year‑old elderly male. Three months prior to admission, he developed chest tightness and shortness of breath without obvious precipitating factors, which failed to improve after rest. He presented to Ulanqab Central Hospital, and cardiac workup demonstrated status post combined mitral‑aortic mechanical valve replacement with normal prosthetic valve function, biatrial enlargement, severe tricuspid regurgitation, and tachycardia. He revisited the outpatient clinic for further management and was hospitalized with the chief complaint of “valvular heart disease and tricuspid regurgitation”. Targeted oral medications including diuretics yielded poor clinical response after admission. Severe tricuspid regurgitation was further confirmed by echocardiographic assessment. After comprehensive evaluation of his clinical status, transcatheter tricuspid annuloplasty was scheduled.
Oral Medications : Regular oral Warfarin ¾ tablet once daily; Metoprolol 12.5 mg once daily (irregular use); Furosemide 20 mg once daily.
Pre‑procedural CT Assessment
Annular dilatation; diastolic tricuspid annular circumference: 15.4 cm; annular area: 18 cm²; septolateral diameter: 40 mm; anteroposterior diameter: 50 mm. Coronary artery courses toward the atrial side; the closest coronary segment is adjacent to the posterior leaflet near the posteroseptal commissure with a minimal distance of 4.1 mm; the coronary artery runs flush with the annulus at the posteroseptal commissure.
Pre‑procedural Echocardiographic Assessment
Status post double‑valve replacement (DVR); tricuspid regurgitation (severe, VCW 10.5 mm, grade 4+); tricuspid annular dilatation; mean annular diameter 40.2 mm; no significant leaflet prolapse or tethering; EROA 0.7 cm²; regurgitant volume 50 mL; regurgitant orifice predominantly central with minor anteroseptal components; estimated pulmonary artery systolic pressure 39 mmHg; TAPSE 12 mm.
Pre‑procedural tricuspid regurgitation
Pre‑procedural 3D regurgitation view
Procedural Strategy
K‑Clip strategy: dual‑clip strategy (16T + 16T).
Case Characteristics
1. Functional tricuspid regurgitation (FTR) with prominent septolateral annular dilatation. Precise localization at posteroseptal and anteroposterior commissures is required for accurate annular anchoring to reduce gaps between septal and anteroposterior leaflets. Sufficient precision can achieve outcomes comparable to surgical repair. With the K‑Clip® Transcatheter Tricuspid Annuloplasty System, the dilated tricuspid annulus is percutaneously plicated to effectively resolve regurgitation and relieve symptoms without native leaflet injury, accomplishing “physiological repair”.
2. Status post mitral mechanical valve replacement, causing substantial interference to intra‑procedural ultrasound imaging. Multi‑plane imaging is required to bypass artifacts for accurate localization of the annulus and leaflet gaps.
Operative Narrative
1. Delivery of the first 16T device: after large sheath advancement, the sheath is retracted and device deflection is oriented toward the tricuspid posteroseptal commissure.
First large sheath advanced into atrium
Retraction of the first large sheath
First‑device deflection aligned to the posteroseptal commissure
2. Screw anchor deployment: the anchoring screw is driven into the hinge region of the tricuspid annulus at the posteroseptal commissure.
First anchor engaged at the annulus
3. Clip arms are adjusted to be flush with the annulus and brought into apposition. Clip deployment at the posteroseptal commissure is completed under digital subtraction angiography (DSA) guidance.
Opening of clip arms and orientation adjustment for first device
Clip arms of first device apposed to the annulus
Completion of first clip deployment assisted by DSA
4. The second 16T device is manipulated in identical fashion and deployed at the anteroposterior commissure.
Second device aligned to the anteroposterior commissure
Second anchor engaged at the annulus
Opening of clip arms and orientation adjustment for second device
Clip arms of second device apposed to the annulus
Completion of second clip deployment assisted by DSA
5. DSA acquisition after deployment of both clips.
Pre‑ versus Post‑procedural Regurgitation Comparison
Pre‑procedural regurgitation
Pre‑procedural tricuspid regurgitation
Post‑procedural 3D regurgitation view
Post‑procedural regurgitation
Post‑procedural right ventricular inflow‑outflow tract regurgitation
Post‑procedural 3D regurgitation view
Pre‑ versus Post‑procedural Tricuspid Annular Area Comparison
Pre‑procedural tricuspid annular area: 15.9 cm²
Post‑procedural tricuspid annular area: 7.95 cm²
Operator's Comments
1. This case of severe tricuspid regurgitation after double mechanical valve replacement represents a typical complex patient with recurrent disease after cardiac surgery and high risk for re‑sternotomy. Minimally‑invasive transcatheter intervention yielded marked tricuspid annular reduction. Tricuspid regurgitation was reduced from grade 4+ to grade 1+, with substantial amelioration of regurgitation, symptomatic improvement and enhanced quality of life.
2. This case demonstrates the breakthrough value of transcatheter tricuspid annuloplasty for patients at high surgical risk. For high‑risk patients with severe annular dilatation, large leaflet coaptation gaps and prohibitive risk of surgical sternotomy, K‑Clip® provides an effective minimally‑invasive therapeutic option. Individualized selection of clip sizes enables precise plication of the dilated annulus, restoration of physiological leaflet coaptation and significant reduction of regurgitant burden. This approach can rapidly improve symptoms, enhance long‑term quality of life, slow right‑ventricular functional deterioration, and potentially restore cardiac function from NYHA functional class Ⅲ to class Ⅱ or Ⅰ, while preserving ample room for subsequent therapies in lifelong cardiac management. The successful completion of this procedure marks a new milestone for regional minimally‑invasive interventional capabilities for severe valvular heart disease.
Expert Introduction
Li Peng
Ulanqab Central Hospital (click to view full expert biography)
K‑Clip® Transcatheter Tricuspid Annuloplasty System:
1. Vascular puncture access with minimal trauma; outer sheath diameter 18 Fr.
2. Simple manipulation performed entirely on the atrial side with a short learning curve.
3. All procedural steps prior to release are reversible, conferring controllable procedural outcomes.
4. Physiological annuloplasty technology without injury to native leaflets.
