Prosthesis In Tricuspid Position Research Articles

Two case reports of transcatheter valve-in-valve implantation of Sapien 3 and MyVal in degenerated biological tricuspid prosthesis valves

BackgroundPatients with severe tricuspid valve stenosis or dysfunction following degeneration of biological valve prosthesis in tricuspid position are complex, have substantial comorbidity, and very high surgical risk.Case summaryWe report two cases with transcatheter tricuspid valve-in-valve implantation in patients with degenerated tricuspid bioprosthesis with transfemoral and transjugular access with Sapien 3 valve and MyVal, respectively.DiscussionIn patients with high surgical risk, transcatheter tricuspid valve implantation is a good alternative. Careful consideration of optimal access site, device size, and delivery system is paramount. This case report demonstrates technically feasible and safe transcatheter valve-in-valve implantantion in tricuspid position and highlights the importance of meticulous procedure planning.

P1149Subcutaneous implantable cardioverter-defibrillator when Transvenous ICD is not a viable option

Abstract Funding Acknowledgements NO FUNDING OnBehalf RHYTHM DETECT Registry Background The class of recommendation for S-ICD implantation in patients who have inadequate vascular access is I according to AHA-ACC-HRS Guidelines and IIb according to ESC Guidelines. Data are lacking about the use of S-ICD for patients in which a transvenous ICD is not a viable option because of the inability to deploy a transvenous lead. Purpose To describe current practice and to measure outcomes associated with S-ICD use in patients in which a transvenous ICD is not a viable option. Methods 942 consecutive patients underwent S-ICD implantation at 22 Italian centers from 2014 to 2019. We identified 101 (11%) patients who received S-ICD because of the reported impossibility of deploying a transvenous lead. Results 21 patients presented with inadequate vascular access but no previous device in place. One patient had a mechanical prosthesis in tricuspid position. The remaining 79 patients received the S-ICD after removal of a prior system implanted, and venous occlusion was diagnosed after lead extraction, or partially or completely failed lead removal. In 24 of these patients a functional transvenous pacing system was left in place for persisting pacing needs. Patients were 60 ± 15 years old, 85% were male, 77% had ischemic or non-ischemic dilated cardiomyopathy, ejection fraction was 36 ± 13%. At implantation, acute conversion test was performed in 64 patients and shock energy of ≤65J was successful in 62 (96.9%) patients. During a median follow-up of 18 months, 6 patients died for non-device related reasons and 1 patient underwent heart transplantation. One patient underwent device replacement for battery depletion and one patient underwent leadless pacemaker implantation. Minor complications (hematomas not requiring system revision) were reported in 2 patients. Appropriate therapies were delivered in 4 patients and 8 patients experienced inappropriate therapies (in 3 patients due to double counting during pacing); all resolved with device reprogramming. Conclusions: In current clinical practice, a minority of S-ICD patients receive the device because of inadequate vascular access. The profile of these patients is similar to that of the typical ICD population in the context of primary sudden death prevention, but many of them present with pacing indications. Acute and mid-term efficacy of S-ICD seemed high. Few complications occurred during follow-up. Particular attention must be paid to device programming for those patients with concomitant pacing systems, in order to prevent inappropriate therapies.

Bicuspidization of the tricuspid valve: A repair option for severe acute endocarditis

Introduction: Tricuspid valve endocarditis is challenging because in most cases there are multiple leasons requiring complex repair and the anterior leaflet is often involved. Frequently, treatment has been valve replacement, associated with the well-known morbidity of valve prostheses in tricuspid position. Some techniques for repair of infected tricuspid valves have been reported aiming at preservation of the valve by using autologous or foreign pericardium with varying results due to shrinking.

An unusual fistula closed by percutaneous coil embolisation

A 25-year-old male patient was admitted for assessment of increasing shortness of breath and decreased transcutaneous oxygen saturation (91 %). He had a complex congenital heart defect, involving a dysplastic monocusp tricuspid valve and pulmonary valve atresia. The latter was palliated shortly after birth by a Brock procedure (entailing infundibular resection and pulmonary valvotomy). An atrial septal defect was surgically closed when he was 6 years old and a homograft was inserted in the right ventricular outflow tract at the age of 15. Replacement by a second homograft at the age of 23 was necessary together with tricuspid valvoplasty because of severe insufficiency of both valves. Apart from moderate pulmonary homograft stenosis (PHS) and re-occurrence of moderate to severe tricuspid insufficiency (TI) resulting in right heart failure, a right-left shunt was detected on transoesophageal echocardiography during intravenous agitated saline bubble-contrast injection, although the repaired atrial septum was intact. Invasive evaluation confirmed moderate to severe TI and a peak-to-peak gradient of 40 mmHg over the homograft. Right atrial pressures were above 20 mmHg. Contrast injection in the superior vena cava showed a very tortuous fistulous connection originating from the left axillary vein and draining towards the left atrium (Fig. 1, panel A and B). It was decided to close the fistula percutaneously and 4 coils (3 x IMWCE-3-PDA3 and 1 x IMWCE-3-PDA5, COOK MEDICAL, Bloomington, USA) were placed in the fistula, effectively occluding the vessel (panel C). The transcutaneous oxygen saturation increased slightly. Further management regarding the TI and PHS will be discussed with one option being percutaneous placement of a pulmonary valve (Medtronic, Minneapolis, USA), possibly in combination with another transcatheter valve prosthesis in tricuspid position to lower the right heart filling pressures. Fig. 1 a Contrast injection in the superior vena cava (SVC) showing a fistula (arrow) originating from the left axillary vein (AV). The right atrium (RA) is grossly enlarged (LIV left innominate vein). b Selective contrast injection in the fistula (arrow) reveals ...

Implantation of a Melody® valve in triscuspid position

A transcatheter pulmonary valve (Melody) was implanted within a stenotic biological valve prosthesis in tricuspid position, as an alternative to the fourth major cardiac surgery in a 12-year-old girl. There were no complications. The postinterventional result was very good.

Implantation of Cryopreserved Mitral Allograft into the Tricuspid Position in an Experimental Study in Sheep: Technical Aspects of Implantation and Immediate Results Evaluated by Epicardial Echocardiography

Cryopreserved mitral allograft valve (MAV) offers theoretical advantages over conventional mechanical or biological prostheses in tricuspid position, especially in infectious endocarditis patients. MAV processing and tricuspid valve (TV) replacement in a sheep model is described. In 20 adult sheep, MAV were harvested, processed and cryopreserved. One month later, recipient's TV were excised and the MAVs were transplanted into the tricuspid position in 13 sheep, under general anaesthesia, via a right thoracotomy, with an extracorporeal circulation (ECC) and cardioplegic heart arrest. Both MAV papillary muscles were anchored into the right ventricular wall by transmural stitches and the MAV anulus was sewn into the recipient's tricuspid anulus. After weaning from ECC, the anatomy and function of the MAV in the tricuspid position was assessed by epicardial echocardiography. The average duration of the ECC was 58 minutes (42-88), the cardioplegic heart arrest was 36 minutes (28-45). Weaning from EEC was always uneventful. Right atrial & pulmonary artery pressure measurements and epicardial echocardiography documented good function of all MAVs. MAV remained mechanically strong enough for implantation into the tricuspid position. Reproducible technique of MAV transplantation into the tricuspid position with excellent early postoperative haemodynamic performance was developed.

Biological or mechanical prostheses in tricuspid position? a meta-analysis of intra-institutional results

Background Tricuspid valve replacement (TVR) is an uncommon procedure. The use of biological vs mechanical prostheses in TVR has pros and cons. Therefore, we debate the choice between the different types of valves by means of a meta-analysis of studies of the last decade. Methods The heading “tricuspid valve replacement and (bio* or mec*)” was used to retrieve studies from Medline, Current Contents, and Embase. Eight out of 11 studies met the preset strict criteria: intra-institutional comparison of results of biological or mechanical TVR. Survival of hospital-discharged patients was recalculated to reduce the effect of unbalanced perioperative risk factors on overall survival. Hazard ratio was obtained from actuarial survival graphics comparison and at-risk groups, according to the method described by Parmar . If missing, the number of patients at risk was approximated assuming constant and noninformative censoring. Hazard pooling was done according to study heterogeneity. Bioprostheses were assumed as the gold standard and mechanical prostheses assumed as the challenging device. Therefore, a hazard more than 1 pointed to a higher risk of mechanical prostheses. Our 1998 study was updated for this analysis. Results In this study, 1,160 prostheses and 6,046 follow-up years were analyzed. The pooled survival hazard ratio of mechanical prostheses versus bioprostheses was 1.07 (0.84 to 1.35, p = 0.60). The pooled freedom from reoperation hazard ratio was 1.24 (0.67 to 2.31, p = 0.67). Pooled survival differences were trivial, favoring mechanical prostheses at 1 (−0.04%) and 15 years (−1.1%) and favoring bioprostheses (+1.8%) at 10 years. Conclusions There is not a gold standard in tricuspid prostheses replacement. Prosthetic choice is left to the surgeon's clinical judgment, taking into consideration each patient's characteristics and needs.

Malfunction of Bjork-Shiley valve prosthesis in tricuspid position.

Eight months after triple valve replacement with Björk-Shiley tilting disc valves a patient developed symptoms and signs suggesting malfunction of the prosthesis in the tricuspid position. This was confirmed by echocardiography and angiocardiography, and at operation thedisc of the prosthesis was found to be stuck half-open by fibrin and clot. A further 11 patients with the same tupe of prosthesis in the triscupid position were then studied by phonocardiography and echocardiography. In one of these the prosthesis was found to be stuck and this was confirmed by angiocardiography and surgery. These 2 cases are reported in detail and the findings in the other 10 are discussed. The implications of this high incidence of malfunction of the Björk-Shiley prosthesis in the tricuspid position are considered. Echocardiography appears to be essential in the follow-up of such patients.