One-stop pulmonary artery denervation and transcatheter tricuspid annuloplasty in combined pre- and post-capillary pulmonary hypertension with severe tricuspid regurgitation

A 64-year-old woman with persistent atrial fbrillation, status post mitral-transcatheter edge-to-edge repair, presented with exertional chest tightness and bilateral edema. Transthoracic echocardiography revealed severe biatrial dilation (left atrium 83 mm, right atrium 55 mm), massive tricuspid regurgitation (TR) (effective regurgitant orifice area (EROA): 0.98 + 0.08 + 0.07 = 1.13 cm2) (Panel B), and pulmonary hypertension (PH) (PASP 56 mmHg). Right heart catheterization confirmed combined pre- and post-capillary pulmonary hypertension (CpcPH) (mPAP 35 mmHg, PCWP 28 mmHg)). Given high perioperative risk, a combined pulmonary artery denervation (PADN) and transcatheter tricuspid annuloplasty (K-Clip) was performed. During the PADN procedure, Swartz sheath compression of the tricuspid valve exacerbated the right-to-left shunt, resulting in a transient hypoxemia. After the PADN, mPAP and PCWP decreased to 23 and 18 mmHg, respectively (Panel A). K-Clip implantation reduced TR to moderate (EROA: 0.22 + 0.06 + 0.08 = 0.34 cm2) with 38.8% annular reduction (Panels B and C). Symptoms resolved immediately, and the patient was discharged within a week.