Embolic protection for tricuspid valve-in-valve intervention

Embolic protection for tricuspid valve-in-valve intervention 1748 Cardiovascular flashlight doi:10.1093/eurheartj/ehx627 CARDIOVASCULAR FLASHLIGHT Online publish-ahead-of-print 28 October 2017 ................................................................................................................................................... Fabien Praz*, Isaac George, Omar K. Khalique, and Susheel K. Kodali Department of Medicine, Division of Cardiology, Columbia University Medical Center/New York-Presbyterian Hospital, 177 Fort Washington Avenue, New York, NY 10032, USA * Corresponding author. Tel: 112123054728, Fax: 112123423811, Email: fp2368@cumc.columbia.edu A 41-year-old woman known for Ebstein’s anomaly was admitted to the hospital for acute hypoxic respiratory distress (New York Heart Association Class IV). A transoesophageal echocardiogram revealed thickened valve leaflets consistent with valve thrombosis 1 year after surgical placement of a 33-mm St. Jude Epic bioprosthesis for treatment of severe tricuspid regurgitation (Panel A). Restricted excursion of the valve leaflets resulted in a decreased effective orifice area of 0.63 cm by transoesophageal echocardiography (Panel B). Percutaneous tricuspid valve-in-valve implantation was planned as a bridge to repeat valve surgery. There was an associated small atrial septal defect (ASD) (5 mm) with right-to-left shunting (Panel C). Because of the large thrombus burden and the risk of paradoxical embolism through the ASD, temporary Doppler-controlled occlusion of the ASD using a 6-mm Admiral percutaneous transluminal angioplasty (PTA) balloon was performed (Panel D). A 29-mm Edwards SAPIEN 3 valve was successfully deployed in the surgical valve via femoral venous access (Panel E;see Supplementary material online, Video S1). As a consequence of the instantaneous haemodynamic improvement, inversion of the shunt direction was observed (Panel F). In the absence of haemodynamic relevance, percutaneous ASD closure was not performed. After an uneventful post-operative course, the patient was discharged after 4 days under oral anticoagulation. Echocardiographic follow-up 9 months after the procedure confirmed excellent valve function (mean gradient 4 mmHg, no regurgitation). When planning a tricuspid valve-in-valve intervention, preventive measures for embolic protection should be considered in the presence of an ASD with paradoxical flow (not infrequently encountered in Ebstein patients), particularly in the setting of valve thrombosis or severe calcification. Supplementary material is available at European Heart Journal online. V C Published on behalf of the European Society of Cardiology. All rights reserved. The Author 2017. For permissions, please email: journals.permissions@oup.com. Downloaded from https://academic.oup.com/eurheartj/article-abstract/39/19/1748/4571853 by Ed 'DeepDyve' Gillespie user on 21 June 2018 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png European Heart Journal Oxford University Press

Embolic protection for tricuspid valve-in-valve intervention

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Oxford University Press
Copyright
Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2017. For permissions, please email: journals.permissions@oup.com.
ISSN
0195-668X
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1522-9645
D.O.I.
10.1093/eurheartj/ehx627
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Abstract

1748 Cardiovascular flashlight doi:10.1093/eurheartj/ehx627 CARDIOVASCULAR FLASHLIGHT Online publish-ahead-of-print 28 October 2017 ................................................................................................................................................... Fabien Praz*, Isaac George, Omar K. Khalique, and Susheel K. Kodali Department of Medicine, Division of Cardiology, Columbia University Medical Center/New York-Presbyterian Hospital, 177 Fort Washington Avenue, New York, NY 10032, USA * Corresponding author. Tel: 112123054728, Fax: 112123423811, Email: fp2368@cumc.columbia.edu A 41-year-old woman known for Ebstein’s anomaly was admitted to the hospital for acute hypoxic respiratory distress (New York Heart Association Class IV). A transoesophageal echocardiogram revealed thickened valve leaflets consistent with valve thrombosis 1 year after surgical placement of a 33-mm St. Jude Epic bioprosthesis for treatment of severe tricuspid regurgitation (Panel A). Restricted excursion of the valve leaflets resulted in a decreased effective orifice area of 0.63 cm by transoesophageal echocardiography (Panel B). Percutaneous tricuspid valve-in-valve implantation was planned as a bridge to repeat valve surgery. There was an associated small atrial septal defect (ASD) (5 mm) with right-to-left shunting (Panel C). Because of the large thrombus burden and the risk of paradoxical embolism through the ASD, temporary Doppler-controlled occlusion of the ASD using a 6-mm Admiral percutaneous transluminal angioplasty (PTA) balloon was performed (Panel D). A 29-mm Edwards SAPIEN 3 valve was successfully deployed in the surgical valve via femoral venous access (Panel E;see Supplementary material online, Video S1). As a consequence of the instantaneous haemodynamic improvement, inversion of the shunt direction was observed (Panel F). In the absence of haemodynamic relevance, percutaneous ASD closure was not performed. After an uneventful post-operative course, the patient was discharged after 4 days under oral anticoagulation. Echocardiographic follow-up 9 months after the procedure confirmed excellent valve function (mean gradient 4 mmHg, no regurgitation). When planning a tricuspid valve-in-valve intervention, preventive measures for embolic protection should be considered in the presence of an ASD with paradoxical flow (not infrequently encountered in Ebstein patients), particularly in the setting of valve thrombosis or severe calcification. Supplementary material is available at European Heart Journal online. V C Published on behalf of the European Society of Cardiology. All rights reserved. The Author 2017. For permissions, please email: journals.permissions@oup.com. Downloaded from https://academic.oup.com/eurheartj/article-abstract/39/19/1748/4571853 by Ed 'DeepDyve' Gillespie user on 21 June 2018

Journal

European Heart JournalOxford University Press

Published: Oct 28, 2017

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