The American College of Cardiology (ACC), American Heart Association (AHA), American Society of Echocardiography (ASE), Heart Rhythm Society (HRS), and Society of Thoracic Surgeons (STS) recently released a consensus document on tricuspid valve intervention programs. The guidance provided within the publication, Recommendations and Requirements for Tricuspid Interventions, is meant to enhance the safety and effectiveness of managing patients with severe tricuspid regurgitation.

Specifically, the consensus guidance is focused on the treatment of native-valve severe tricuspid regurgitation with devices approved by the U.S. Food and Drug Administration (FDA). It does not focus on the use of transcatheter aortic valves for treatment of bioprosthetic TV failure or recurrent severe TR after surgical TV annuloplasty.

Recommendations and Requirements for Tricuspid Interventions is divided into three main sections, with each section having its own subsections. The largest section is Patient Evaluation and Selection, which we are highlighting below. View the full-text version of the publication for the complete look at the guidance suggested by the ACC/AHA/ASE/HRS/STS consensus.

Key Highlights of the ACC/AHA/ASE/HRS/STS Guidance

Multidisciplinary Team Member Requirements for TTVI: 

  • Advanced practice providers
  • Cardiac anesthesiologist
  • Cardiac valve surgeon
  • Data manager
  • Electrophysiologist, CIED expert
  • General/valve cardiologist
  • Heart failure specialist
  • Interventional cardiologist
  • Interventional echocardiographer
  • Multimodality imaging specialist (with CT and CMR expertise)
  • Other subspecialty expertise as clinically appropriate
  • Program navigator
  • Structural heart coordinator

The Importance of Shared Decision Making

The guidance states that patients should be well educated regarding treatment options and availability, understand the patient-specific risks and benefits of those treatment options, establish treatment goals and recovery goals, make note of any preferences and/or values related to their care, and use all that information to make a treatment choice.

Facilities and Institutional Requirements

Institutions offering a tricuspid valve intervention program should have an active cardiac surgical program, comprehensive diagnostic imaging services, and therapeutic facilities. The guidance states that only institutions with well-established interventional cardiology programs should offer TTVI, specifically programs that include expertise in percutaneous coronary intervention, transcatheter aortic valve implantation, M-TEER, balloon valvuloplasty, catheter closure of periprosthetic leaks, and deployment of septal closure devices.

The guidance goes on to list out facilities and equipment that are essential for a tricuspid valve intervention program: 

  • Accredited cardiac catheterization laboratory or hybrid operating room/catheterization laboratory
  • Non invasive cardiovascular imaging programs
  • Postprocedural recovery and intensive care facilities with telemetry monitoring, staffed by physicians, advanced practice providers, and nurses trained and experienced in managing patients who have undergone transcatheter valve procedures
  • Outpatient facilities including office space adequate to accommodate medical, nursing, and technical personnel and ancillary testing facilities that can provide timely, high-quality care
  • Support services for coordination of postdischarge care

Requirements for Establishing and Managing a TTVI Program

The publication features a rundown of criteria for initiating a T-TEER or TTVR program:

  • ≥50 open heart surgeries in the previous year.
  • ≥20 tricuspid valve surgeries (isolated or combined) in the two years prior.
  • ≥2 physicians with cardiac surgery privileges.
  • ≥1 physician with interventional cardiology privileges.
  • ≥1 physician with interventional echocardiography privileges.
  • 1 board-certified/board-eligible cardiac EP available for pacemaker implantation or lead extraction when required.
  • ≥50 TAVI and ≥20 TEER procedures per year or ≥100 TAVI and ≥40 TEER in previous two years.
  • ≥200 complete TEE performed per year or ≥400 complete TEE performed over the previous two years.

Requirements for catheter operator to establish a T-TEER or TTVR program:

  • ≥50 career structural valve procedures of which ≥20 are TEER procedures.
  • Board eligibility, equivalency, or certification in either interventional cardiology or cardiothoracic surgery.
  • Certification of device-specific training.

Requirements for interventional echocardiographer operator to establish a T-TEER or TTVR program:

  • ≥50 career structure valve disease procedures, of which ≥20 are TEER procedures
  • Level 3 or equivalent board eligibility or certification in echocardiography.
  • Certification of device-specific training.

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