Transjugular Tricuspid Valve-in-Valve Replacement

Abstract

The patient is a 38-year-old woman with rheumatic heart disease requiring surgery 21 years ago. She received a St. Jude mechanical prosthesis in the mitral position and a Carpentier-Edwards Perimount bioprosthesis (size 31) in the tricuspid position. Over the past 2 years, she has become progressively more short of breath with regular admissions for congestive heart failure despite medical treatment. Transthoracic echocardiography showed a severely dilated right atrium and a calcified tricuspid prosthesis with a mean gradient across the valve varying between 9 and 12 mm Hg (Figures 1 and 2). The mitral valve prosthesis functioned well. Figure 1. The continuous wave spectral Doppler of the degenerate tricuspid prosthesis before the procedure showing a profile of severe tricuspid stenosis with averaged (because of atrial fibrillation) peak and mean gradients of 12 and 9, respectively. Vmax indicates maximum flow velocity; Vmean, mean flow velocity; Pmax, maximal pressure gradient: Pmean, mean pressure gradient; Env Ti, duration of measured envelope; VTI, velocity time integral; HR, heart rate. Figure 2. Pressure half-time (PHT) measured over the tricuspid valve confirms severe tricuspid stenosis with a value of 461 ms. A decision was made to replace the tricuspid valve, but in consultation with the heart team, it was agreed that, given that the mitral valve prosthesis was functioning well, the risk of a second sternotomy to replace only the tricuspid valve was difficult to justify if an alternative option was available. Given the limited lifespan of a bioprosthesis in a young person, she would then require her third (and likely final) sternotomy at a young age. A joint decision was therefore made to offer the patient a minimally invasive tricuspid valve replacement by a transcatheter procedure. The risks of a transcatheter procedure were discussed with her, and she provided written informed consent. The option of a …