Tricuspid regurgitation (TR) is often underestimated and undertreated. Evidence in the literature indicates that isolated significant TR increases mortality, regardless of left ventricular ejection fraction, pulmonary pressures, or right ventricular (RV) dysfunction.¹ Clinical management typically involves escalating doses of diuretics, though efficacy remains limited due to the progressive nature of the disease and structural changes caused by systemic hypervolemia. Surgery for isolated TR is associated with a high mortality rate, ranging from 4% to 20%.² As a result, interventional therapies, especially percutaneous treatments, have gained attention due to their less invasive profile. The TricValve® system, a bicaval valve prosthesis, was developed to mitigate reflux responsible for volume overload in patients with severe TR. Studies have demonstrated that the device effectively reduces systemic congestion, leading to improved quality of life and better functional status.³

A 61-year-old female patient with a history of rheumatic mitral valve disease who had undergone mitral valve replacement with a metal prosthesis 16 years prior presented with progressive dyspnea, leg edema, abdominal discomfort, and asthenia. On physical examination, she exhibited an irregular heart rhythm, jugular vein distension, lower limb edema, a systolic murmur along the lower left sternal border, and a metallic click in the first heart sound.

Electrocardiography revealed atrial fibrillation with a controlled heart rate. Echocardiography demonstrated torrential TR due to annular dilation and leaflet tethering, with significant leaflet separation and a 6.6-mm gap, resulting in a regurgitant volume of 119 mL (Figure 1). The metallic mitral prosthesis displayed preserved opening with mild reflux. Left ventricular and RV systolic function were normal, while both the left atrium and right atrium (RA) were significantly enlarged. Cardiac catheterization revealed a prominent "V" wave in the RA and vena cava.

Given the presence of isolated TR, worsening symptoms despite high-dose diuretic therapy, and a high surgical risk (TRI-SCORE = 5), percutaneous treatment was selected. The available transcatheter option at the time was heterotopic implantation of a bicaval prosthesis. The procedure was performed under conscious sedation with primary access through the right femoral vein. Due to significant vena cava dilation at its junction with the RA, the superior vena cava prosthesis was implanted high, with its crown positioned entirely within the brachiocephalic vein. The inferior vena cava device was deployed below its junction with the RA, sealing at the level of the hepatic vein (Figure 2).

The patient recovered well from the procedure; however, on the third postoperative day, she developed a large hematoma at the main access site. Surgical drainage was performed successfully, and she was subsequently discharged from the hospital. At the 12-month follow-up, the patient demonstrated significant improvement in functional class (FC) and quality of life. Physical examination showed no hepatomegaly or lower limb edema. Follow-up imaging confirmed proper prosthesis positioning and effective vena cava sealing (Video 1). Additionally, the patient experienced significant weight loss and had no hospitalizations during this period (Table 1).

Torrential TR with right heart failure presents a therapeutic challenge due to the complex and heterogeneous anatomy of the tricuspid valve, as well as the clinical profile of affected patients. Therefore, evaluation by a multidisciplinary cardiac team is a crucial step in the decision-making process. In this report, we describe the 12-month follow-up results after implantation of the TricValve® system. The patient, a 61-year-old woman with isolated functional torrential TR, initially presented in FC III with systemic hypervolemia refractory to optimized medical therapy. Despite her relatively young age, surgery was deemed high-risk due to prior cardiac surgery, isolated tricuspid valve disease, and a TRI-SCORE-predicted in-hospital mortality of 14%.³ Bicaval valve implantation has emerged as a viable option for patients unsuitable for direct tricuspid valve interventions and those with high or prohibitive surgical risk. At the 12-month follow-up, the patient had improved to FC I, experienced significant weight loss, and showed reduced signs of hypervolemia. This outcome aligns with existing literature, where nearly 80% of patients achieved FC I or II status at the 6-month follow-up.^4,5

From a pathophysiological perspective, after device implantation in the vena cava, the RA effectively becomes part of the RV, leading to increased pressure in this chamber, which functions as a blood reservoir. Consequently, an increase in RA size is commonly observed during follow-up, as seen in the reported case. When comparing echocardiographic parameters, we noted a progressive increase in RA size, stability of RV function, and persistence of torrential TR. Regarding TR, studies suggest that while the TricValve® does not directly alter valve leaflet function, it may have a positive impact by relieving the RV from chronic volume overload. Up to the current follow-up period, cardiac magnetic resonance imaging demonstrated a reduction in RV volume between the 6-month and 12-month evaluations, with preservation of global systolic function. Structural changes may occur over longer follow-up periods, a phenomenon previously described in patients monitored for more than 6 months.

Vascular complications are reported in up to 20% of cases after the procedure and are associated with factors such as the large caliber of the device, anticoagulation use, and the clinical profile of these patients, all of which increase the risk of bleeding. The patient was using vitamin K antagonists due to a mechanical mitral prosthesis, and the hematoma occurred after reintroducing the medication. Another concerning complication is valve migration, which may be attributed to variations in volume status, difficulty in anchoring the device due to vena cava dilation from chronic volume overload, and the absence of calcified structures.⁶ In this case, echocardiography and cardiac magnetic resonance imaging demonstrated prosthesis stability, proper leaflet function, and the absence of significant paravalvular leakage during follow-up.

Percutaneous implantation of the TricValve® system resulted in a significant improvement in quality of life, as well as in signs and symptoms related to systemic hypervolemia, without compromising RV function at the 12-month follow-up after the procedure. Future studies with a larger patient population and long-term follow-up are needed to further validate this therapy and enhance the understanding of patient outcomes.