Mitral and Tricuspid TEER, Antalya | Prof. Dr. Umuttan Doğan

When a heart valve does not close fully, some of the blood leaks back the way it came. This is called valve regurgitation, or a leaking valve. Treating a leaking mitral valve was for many years possible only with open surgery. TEER (transcatheter edge-to-edge repair) reduces the leak by joining the two leaflets of the valve with a small clip; it is often referred to simply as the clip procedure. It goes in through the vein in the groin, and the chest is not opened. The same method can be used for a leaking tricuspid valve.

What Does a Leaking Valve Mean?

Heart valves are one-way doors. Once the blood has passed, they close and stop it coming back. If they do not close completely, a little blood leaks backwards with every beat.

The heart works harder to make up for that loss. Over time the chambers enlarge and heart failure can develop.

A Leaking Mitral Valve

The mitral valve lies between the left atrium and the left ventricle. When it leaks, some of the blood that should be going out to the body turns back towards the lungs. That is why breathlessness is the clearest symptom.

A Leaking Tricuspid Valve

The tricuspid valve lies between the right atrium and the right ventricle. When it leaks, blood backs up on the side returning from the body — towards the liver and the legs. The symptoms are therefore different: swelling in the legs and the abdomen, fullness in the veins of the neck, loss of appetite and tiring easily.

The tricuspid was long regarded as the valve that did not matter. It is now known that, left untreated, a leak there can make heart failure worse.

What Are the Symptoms?

A leak can stay quiet for years. Often the first sign is a murmur heard during an examination.

Breathlessness on exertion, appearing with lighter effort as time goes on
Breathlessness lying down at night, needing to sleep on more pillows
Tiring easily, and weakness
Palpitations, particularly once atrial fibrillation is added
Swelling in the feet and legs
With a tricuspid leak: a swollen abdomen, loss of appetite, fullness in the neck

Primary or Secondary? Why That Distinction Matters

This is the most decisive thing on the page, and most sources leave it out. The cause of the leak changes the choice of treatment directly.

A primary (degenerative) leak: the problem is in the valve itself. A leaflet has prolapsed or stretched, or one of the cords holding it has ruptured. The valve is faulty while the heart muscle is largely sound.

A secondary (functional) leak: the valve is structurally normal. The chamber of the heart has enlarged, so the ring the valve sits in has widened too and the leaflets can no longer reach each other. The real problem is in the heart muscle, not the valve.

The distinction decides this: in a secondary leak, treatment for heart failure has to be brought to its optimal level first. A valve procedure done before the medication has been properly adjusted may not deliver the expected benefit.

How Is It Diagnosed?

Examination: a leaking valve has a characteristic murmur.
Echocardiography: it shows how severe the leak is, what is causing it and the state of the heart chambers. This is the main test.
An echo from the gullet: the detailed structure of the valve cannot always be seen through the chest wall. In this test the probe is placed in the oesophagus and the valve examined from very close by. Where a procedure is being planned, this test is required.
ECG and rhythm monitoring: whether atrial fibrillation is present as well.
Coronary angiography: the state of the coronary arteries is also examined before the procedure.

What Do the Grades of a Leak Mean?

You may have seen something like “grade 1” or “grade 2” on your echocardiogram report. These expressions often cause needless worry.

A leak is usually described at four levels:

Trace or mild (grade 1): common in healthy people too. It needs no treatment, and often not even follow-up.
Moderate (grade 2): followed with echocardiography at set intervals. Where there are no symptoms, a procedure is not considered.
Moderate to severe (grade 3): close follow-up is needed, watching whether the heart chambers are enlarging.
Severe (grade 4): treatment options are assessed.

The critical point is this: the grade does not decide on its own. Of two patients with the same grade, one may be a candidate for a procedure while the other is simply followed. Your symptoms, the measurements of the heart chambers, its pumping strength, the pressure in the lungs and your rhythm are all weighed together.

If your report says “grade 1 mitral regurgitation”, that does not mean treatment for a leaking mitral valve is needed.

What Are the Options for a Leaking Mitral Valve?

There are three, and none is automatically the alternative to another.

Medication: it does not do away with the leak. It reduces the load on the heart and eases symptoms. In a secondary leak it is the basis of treatment.
Open heart surgery: the valve is repaired or replaced. It is the first thing to consider in a primary leak and in patients whose surgical risk is acceptable.
TEER: edge-to-edge repair by catheter. It comes into play where surgical risk is high and the anatomy of the valve is suitable.

What Is TEER?

TEER stands for transcatheter edge-to-edge repair.

The idea is simple. The middle parts of the two leaflets that are not closing properly are fastened together with a small clip. The valve now works through two small openings rather than one large one, and the leak between them narrows.

The method is a catheter version of a repair technique that has been used in surgery for decades. It is not a new idea, then, but a known repair that can now be done without opening the chest.

How Is TEER Carried Out?

At the Mitral Valve

The procedure goes in through the vein in the groin, not the artery. The catheter reaches the right atrium. Because the mitral valve is on the left, a controlled crossing is made through the thin wall separating the two atria. This is called the transseptal crossing.

The system carrying the clip is then brought over the valve, the leaflets are grasped and the clip is closed. How much the leak has reduced is measured by echocardiography at that moment. If it is not enough, a second clip can be added.

At the Tricuspid Valve

The tricuspid valve is on the right side, so no transseptal crossing is needed; the catheter reaches the valve directly from the vein in the groin.

This valve brings a difficulty of its own: the lead of a pacemaker or defibrillator placed earlier may pass through it. That makes the procedure technically harder and is assessed separately at the planning stage.

Why Is a General Anaesthetic Needed?

This is where TEER differs from the other procedures done in the catheter laboratory. The valve has to be imaged continuously from the gullet throughout. Because the probe must be swallowed and you have to stay still for a long time, the procedure is usually done under a general anaesthetic.

That sets it apart from procedures such as TAVI, which can often be done under local anaesthetic.

Who Is TEER For?

Patients with a severe valve leak whose symptoms persist
People for whom open heart surgery carries a high risk
In a secondary leak, those whose symptoms continue although heart failure treatment has been brought to its optimal level
People who have had heart surgery before
Cases where kidney, lung or other organ disease raises the surgical risk

When TEER Is Not Suitable

Suitability depends not only on the patient’s general condition but on the anatomy of the valve. The decision is therefore made after the detailed echocardiogram from the gullet.

If the leaflets are not long enough for the clip to grasp
If the gap between the leaflets is too wide
If there is heavy calcification where the clip would grasp
If the valve is markedly narrowed as well as leaking; the clip narrows the opening further
If surgical repair is suitable and the patient’s surgical risk is low

The decision is not made by one doctor. It is reached through a process in which cardiology and cardiac surgery give their views together, which is what international cardiology guidelines recommend.

Does the Leak Go Away Completely?

An honest answer to this matters.

The aim of TEER is to reduce the leak, not to abolish it. Bringing a severe leak down to mild or moderate is regarded as meaningful in terms of the load on the heart. In some patients the leak almost disappears; in others some of it remains.

The clip also narrows the valve a little. The aim is to strike the balance correctly: to reduce the leak enough without creating a new narrowing. That balance is measured continuously during the procedure.

How Do You Prepare?

The imaging is completed: an echo from the gullet is required. It is what shows whether the valve is suitable for a clip. A CT scan and coronary angiography are added where needed.
Your heart failure treatment is reviewed: in a secondary leak this step matters as much as the procedure itself. A procedure is not planned before the medication has been brought to its optimal level.
Dental check: because a permanent device is being placed in the heart, untreated dental infections are dealt with first. This step is often skipped.
Your list of medicines: bring everything you take, with the doses. Your doctor decides how blood thinners are managed around the procedure.
Anaesthetic assessment: because the procedure is done under a general anaesthetic, the anaesthetist sees you beforehand. You will be told then how long to fast.
Your questions: the expected benefit, the possible risks and the alternatives are explained at the consultation beforehand, and your written consent is taken.

What Are the Possible Risks?

Bleeding, bruising or injury to the vessel at the access site
A small opening left where the wall between the atria was crossed; usually of no consequence, and it is followed
The clip detaching from a leaflet; rare, and a further procedure is planned if needed
Narrowing of the valve to an unwanted degree
The risks that come with a general anaesthetic
Risk of stroke, as with every heart valve procedure

The risks are weighed against the benefit expected from the procedure and discussed in detail for your own situation at the consultation beforehand.

Can You Have Surgery After TEER?

This is a question patients ought to ask and rarely think of.

Once the clip is in, the leaflets are held together. If surgery is needed later, repairing the valve generally becomes harder and replacing it comes onto the table. The order therefore matters: in a patient suitable for surgical repair whose risk is low, TEER is not considered as the first choice.

This is why your age and your expected life span are assessed separately during the decision.

Afterwards

You stay under close observation for the first hours, with the access site and your rhythm watched.
Your heart failure medicines are reviewed. Doses may need changing after the procedure; do not stop them on your own.
Cardiology review and echocardiography are carried out at set intervals.
Say that you have a clip in your heart before any dental work or surgery.
Heart failure advice such as watching salt and fluid and weighing yourself continues.
Activity is increased in stages; cardiac rehabilitation may be recommended.

If you notice worsening breathlessness, sudden weight gain, more swelling in the legs or a fever, see your doctor without waiting.

Treatment for a Leaking Mitral Valve in Antalya

Prof. Dr. Umuttan Doğan is a cardiologist working in the interventional treatment of heart valve disease. Mitral and tricuspid TEER procedures are carried out in the catheter laboratory at Antalya American Hospital.

If your echocardiogram has shown a severe mitral or tricuspid leak, you can be seen at the clinic in Konyaaltı with the results you already have. For narrowing of the aortic valve see TAVI, and for the other procedures the heart valve treatments page. You will find his background and contact details on their own pages.

Frequently Asked Questions

Is TEER an operation? Will my chest be opened?

No. The procedure goes in through the vein in the groin; the breastbone is not opened, the heart is not stopped and no heart-lung machine is used. It is still an interventional procedure, usually needs a general anaesthetic and has risks of its own.

Will the leak be gone completely afterwards?

The aim is to reduce it. Bringing a severe leak down to mild or moderate is regarded as meaningful. In some patients the leak almost disappears; in others some remains. The result is measured by echocardiography during the procedure.

What is the difference between mitral and tricuspid TEER?

The method is the same: the leaflets are joined with a clip. The difference is the route. Because the mitral valve is on the left, the wall between the two atria is crossed. The tricuspid valve is on the right, so that crossing is not needed. Where a pacemaker lead passes through the tricuspid valve, the planning takes account of it.

Will I be awake during the procedure?

Usually not. Because the valve has to be imaged continuously from the gullet, the procedure is mostly done under a general anaesthetic. In that respect it differs from some catheter procedures that can be done under local anaesthetic.

If I have TEER, can I still have surgery later if it is needed?

Because the leaflets are fastened together once the clip is in, repairing the valve at a later operation becomes harder and replacing it may come onto the table. This is why TEER is not considered as the first choice in patients who are suitable for surgical repair and whose surgical risk is low.

The information on this page is for general guidance and does not replace a consultation. Decisions about diagnosis and treatment are made by your doctor after assessing your own situation.