Abstract Transcatheter valve-in-valve implantation within dysfunctional surgical bioprosthesis has become an alternative to redo open-heart surgery. However, suitability for valve-in-valve implantation in the tricuspid position is often limited by large surgical valve sizes. We report a case of a transcatheter tricuspid valve-in-valve implantation with a 29-mm balloon-expandable prosthesis within a 33-mm failed bioprosthesis (exceeding manufacturer’s sizing recommendations). Overexpansion of a 29-mm SAPIEN XT valve by 1-ml overfilling of the deployment balloon was successfully performed, with no valve dislocation/embolization or residual tricuspid regurgitation. This case illustrates the feasibility of tricuspid valve-in-valve procedures in selected patients with large failed tricuspid bioprostheses. Transcatheter valve replacement, Tricuspid valve, Valve in valve, Overfilling INTRODUCTION A 68-year-old woman with Ebstein’s anomaly and left-sided superior vena cava presented with dyspnoea and New York Heart Association (NYHA) functional Class III. The patient reported a history of long-standing tricuspid regurgitation, after prior partial anterior tricuspid leaflet resection with bioprosthetic tricuspid valve replacement using a 33-mm Carpentier–Edwards valve (Edwards Lifesciences, Irvine, CA, USA)—severe Ebstein disease unsuitable for surgical repair—and interatrial communication closure, and a second-staged left Glenn procedure with permanent pacemaker implantation 2 months later due to persistent right failure. Transthoracic echocardiography revealed severe functional tricuspid regurgitation (III–IV/IV), mild right ventricle dysfunction and preserved left ventricular ejection fraction (Fig. 1A). The patient suffered from a decline in exercise tolerance, with low peak O2 consumption (VO2 max 12.7 ml/kg/min), NYHA Class III and signs of chronic right failure despite optimal diuretic dose. Following a multidisciplinary Heart Team decision, the patient was deemed inoperable (high surgical risk—EuroSCORE II: 9%, third redo sternotomy and reduced right ventricular function) and considered for tricuspid valve-in-valve (TVIV) replacement. Figure 1 View largeDownload slide Tricuspid valve-in-valve implantation within a 33-mm failed surgical bioprosthetic valve. (A) Transthoracic echocardiogram (TTE). Parasternal long-axis view showing severe tricuspid regurgitation. (B) Preprocedural computed tomography (CT) measures of the 33-mm bioprosthetic valve: effective internal diameter of 28.4 × 24.9 mm (green and yellow lines), mean inner diameter of 26.5 mm, perimeter of 83.8 mm (red circle) and area of 551 mm2. (C) Fluoroscopic image (right anterior oblique projection). A 29-mm SAPIEN XT was implanted with overfilling of the deployment balloon with 1 ml of additional volume. (D) Fluoroscopic image showing well-apposed and fully deployed transcatheter valve. (E) TTE parasternal long-axis view showing trivial tricuspid regurgitation post-procedure. (F) Postoperative 3D CT reconstruction confirming optimal positioning of the SAPIEN XT valve within the failed 33-mm bioprosthetic valve. Figure 1 View largeDownload slide Tricuspid valve-in-valve implantation within a 33-mm failed surgical bioprosthetic valve. (A) Transthoracic echocardiogram (TTE). Parasternal long-axis view showing severe tricuspid regurgitation. (B) Preprocedural computed tomography (CT) measures of the 33-mm bioprosthetic valve: effective internal diameter of 28.4 × 24.9 mm (green and yellow lines), mean inner diameter of 26.5 mm, perimeter of 83.8 mm (red circle) and area of 551 mm2. (C) Fluoroscopic image (right anterior oblique projection). A 29-mm SAPIEN XT was implanted with overfilling of the deployment balloon with 1 ml of additional volume. (D) Fluoroscopic image showing well-apposed and fully deployed transcatheter valve. (E) TTE parasternal long-axis view showing trivial tricuspid regurgitation post-procedure. (F) Postoperative 3D CT reconstruction confirming optimal positioning of the SAPIEN XT valve within the failed 33-mm bioprosthetic valve. The procedure was performed under local anaesthesia via right femoral vein access, using combined fluoroscopic and transthoracic echocardiography guidance. Baseline mean right atrial pressure determined invasively was 12 mmHg, with a pulmonary artery pressure of 36/18/25 mmHg and a mean wedge pressure of 14 mmHg. To assess the inner diameter (ID) of surgical bioprosthesis, preprocedural computed tomography (CT; Fig. 1B) and intraprocedural balloon calibration with a 28-mm Z-Med balloon (NuMed, Hopkinton, NY, USA) were performed. A 29-mm SAPIEN XT valve (Edwards Lifesciences) was therefore implanted under rapid pacing through the existing pacing system by overfilling of the deployment balloon with 1 extra ml of volume to the 33-ml recommended nominal filling volume (Fig. 1C), with successful valve positioning and deployment (Fig. 1D). Postimplantation transthoracic echocardiography (Fig. 1E) and CT (Fig. 1F) demonstrated the absence of significant tricuspid regurgitation and complete valve apposition. The patient was discharged with no complications under aspirin alone and was asymptomatic at 6-month follow-up. DISCUSSION TVIV implantation within failed tricuspid bioprostheses has emerged as an alternative to surgery in recent years. To date, most TVIV procedures for tricuspid valve dysfunction have been performed with either the Melody (Medtronic, Inc., Minneapolis, MN, USA) or the SAPIEN valves, with comparable outcomes concerning valve performance and safety, albeit the former may be more likely to be used in younger patients with smaller surgical bioprosthesis . Suitability of this technique is often challenged by large tricuspid annulus size, a potential risk factor for valve undersizing leading to paravalvular regurgitation or valve embolization. One limitation of the Melody valve is its maximal diameter (22–24 mm). In the current case, involving a patient with a 33-mm surgical valve, a 29-mm SAPIEN valve was used to guarantee a stable position. Careful preprocedural workup and assessment of the true ID of the surgical valve, usually smaller than the stent ID, and used for transcatheter heart valve (THV)-sizing purposes is crucial when planning TVIV procedures involving large failing bioprosthetic valves . Preprocedural CT evaluation of the effective ID, area and perimeter is paramount to determine a patient’s suitability and THV sizing; intraprocedural balloon sizing is also advisable. Of note, the use of the Valve-in-Valve app, developed by Bapat and UBQO, is of keen interest in the preparation of valve-in-valve procedures. In this case, the size of the surgical valve exceeded the maximum recommended THV size by the app platform. However, preprocedural CT and balloon calibration showed a true ID of 28.4 mm and 28 mm, respectively, somewhat differing from the 31-mm stent ID according to the manufacturer’s specifications. Previous experiences with TVIV implantation within very large annulus are scarce [1–3]. Overexpansion of the SAPIEN valve in the tricuspid position has been restricted to the valve-in-ring approach in a patient with a 32-mm tricuspid annuloplasty ring . Indeed, transcatheter valve-in-ring implantation is often more challenging than TVIV procedures, involving a wide variety of annuloplasty devices with variable shapes, sizes, rigidity and circumferential completeness. Incomplete rings raise the most challenging subset as the lack of sufficient bed for the valve implant might increase the risk of paravalvular leak or valve embolization. In contrast to rigid rings, semirigid complete rings result in less deformation of the THV and therefore are more suited for valve-in-ring procedures . The reported case demonstrates the feasibility of off-label TVIV implantation using a strategy of deliberate overexpansion within a very large degenerated bioprosthetic tricuspid valve exceeding manufacturer charts. Funding This work was supported by a grant of the Fundación Alfonso Martin Escudero (Spain) [to L.A.]; and the Canadian Research Grant ‘Fondation Famille Jacques Larivière’ for the Development of Structural Heart Interventions [to J.R.-C.]. Conflict of interest: none declared. REFERENCES 1 McElhinney DB, Cabalka AK, Aboulhosn JA, Eicken A, Boudjemline Y, Schubert S et al. Transcatheter tricuspid valve-in-valve implantation for the treatment of dysfunctional surgical bioprosthetic valves. An international, multicenter registry study. Circulation 2016; 133: 1582– 93. Google Scholar CrossRef Search ADS PubMed 2 Gopalamurugan AB, Reinthaler M, Mullen MJ. Percutaneous valve-in-valve implantations: importance of knowing the effective internal diameter of bioprosthetic valves. Heart 2013; 99: 1709– 10. Google Scholar CrossRef Search ADS PubMed 3 Cullen MW, Cabalka AK, Alli OO, Pislaru SV, Sorajja P, Nkomo VT et al. Transvenous, antegrade melody valve-in-valve implantation for bioprosthetic mitral and tricuspid valve dysfunction. JACC Cardiovasc Interv 2013; 6: 598– 605. Google Scholar CrossRef Search ADS PubMed 4 Cabasa AS, Eleid MF, Rihal CS, Villarraga HR, Foley TA, Suri RM. Tricuspid valve replacement. A percutaneous transfemoral valve-in-ring approach. JACC Cardiovasc Interv 2015; 8: 1126– 8. Google Scholar CrossRef Search ADS PubMed 5 Pfeiffer S, Gazdag L, Jessl J, Santarpino G. Transapical transcatheter valve-in-ring implantation following mitral annuloplasty. J Card Surg 2017; 32: 407– 9. Google Scholar CrossRef Search ADS PubMed © The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
Interactive CardioVascular and Thoracic Surgery – Oxford University Press
Published: Mar 1, 2018
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