Bioprosthetic Tricuspid Valve Research Articles

Redo isolated tricuspid valve replacement in a patient with isolated persistent left superior vena cava: a case report

BackgroundRedo isolated tricuspid valve surgery has high in-hospital mortality and morbidity and is a challenging procedure. We report a successful case of redo isolated tricuspid valve replacement for structural valve deterioration of a bioprosthesis in a patient with isolated persistent left superior vena cava (PLSVC).Case presentationAn 81-year-old man with a history of tricuspid valve replacement using a porcine bioprosthetic valve 9 years previously presented with dyspnea on exertion. Right heart failure due to worsening transvalvular leakage in the bioprosthetic tricuspid valve was considered to be the cause of his symptoms, and the decision was made to replace the tricuspid valve. An isolated PLSVC is considered to be an obstacle in right-sided heart valve surgery. The PLSVC was located deep to the left of the pulmonary artery and, after some effort, was cannulated by obtaining an excellent surgical view using retraction sutures on the left side of the pericardium. Cardiopulmonary bypass was initiated after cannulation of the ascending aorta, PLSVC, and femoral vein. After cross-clamping of the ascending aorta, cold blood cardioplegic arrest was induced under moderate hypothermia, and the PLSVC and inferior vena cava were snared. The right atrium was opened and the prosthetic tricuspid valve was examined. One of the leaflets was shortened, which appeared to cause the transvalvular leak. The prosthetic valve was explanted, the annulus was trimmed, and a new bioprosthetic valve was implanted. The postoperative course was uneventful.ConclusionsIt is important to treat structural valve deterioration of a prosthetic tricuspid valve in a timely manner. We hope that our intervention timing and surgical strategy can help surgeons to consider early intervention in similar cases, even if there are surgical obstacles such as isolated PLSVC.

May 2024 Medical Image of the Month: Hereditary Hemorrhagic Telangiectasia in a Patient on Veno-Arterial Extra-Corporeal Membrane Oxygenation

No abstract available. Manuscript truncated after 150 words. A 54-year-old man with a complex cardiac history, including Tetralogy of Fallot requiring Blalock-Taussig shunt in infancy, infundibular patch repair at age 7, and bioprosthetic tricuspid valve replacement at age 52, had ongoing frequent hospitalizations with decompensated right ventricular heart failure secondary to native pulmonary valve mixed stenosis plus regurgitation and left pulmonary artery stenosis. His case was further complicated by his history of hereditary hemorrhagic telangiectasia (HHT) with recurrent epistaxis and recent GI bleeds with multiple angiodysplastic lesions throughout the stomach, duodenum, and descending colon which were previously treated with argon plasma coagulation. The patient was admitted to our hospital in NYHA class IV heart failure receiving a continuous dopamine infusion and aggressive diuresis. Upon admission, a right heart catheterization demonstrated severe pulmonary valve regurgitation, left pulmonary artery stenosis, and systemic hypoxemia suggestive of an intrapulmonary shunt. Admission transthoracic echocardiogram demonstrated normal left ventricular ejection fraction of 55-60%, a …

Transthoracic echocardiographic Doppler metrics in evaluating bioprosthetic tricuspid valve dysfunction.

There is currently limited information on the utility of transthoracic echocardiography (TTE)-derived Doppler parameters for assessing bioprosthetic tricuspid valve (BTV) dysfunction. Our study aimed to establish the precision and appropriate reference ranges for routinely collected transthoracic Doppler parameters in the assessment of BTV dysfunction. We retrospectively evaluated 100 BTV patients who underwent TTE. Based on redo surgical confirmation or more than 2 repeat TTE or transesophageal echocardiography (TEE) examinations, patients were allocated to normal (n=61), regurgitant (n=24), or stenotic (n=15) BTV group. Univariate and multivariate binary logistic regression were performed to identify TTE Doppler parameters that detected BTV dysfunction. The VTI ratio (VTITV/VTILVOT) was the most accurate Doppler parameter for detecting BTV dysfunction, with a ratio of>2.8 showing 84.6% sensitivity and 90.2% specificity. VTI ratio>3.2, mean gradient (MGTV)>6.2mmHg and pressure half-time>218ms detected significant BTV stenosis, with sensitivities of 100%, 93.3% and 93.3% and specificities of 82.4%, 75.3% and 87.1%, respectively. After multivariate analysis, the VTI ratio>2.8 (OR=9.00, 95% CI=2.13-41.61, p=.003) and MGTV>5.1mmHg (OR=6.50, 95% CI=1.69-27.78, p=.008) were the independent associations of BTV dysfunction. With these cutoff values, 75.0%-92.2% of normal and 62.5%-96.0% of dysfunctional BTV were identified. Doppler parameters from TTE can accurately identify BTV dysfunction, particularly with VTI ratio>2.8 and MGTV>5.1mmHg, to assess the need for additional testing with TEE.

Restricted cusp motion in newly implanted tricuspid bioprostheses: Incidence, predictors, and impact on survival

ObjectiveTo investigate the occurrence of restricted cusp motion (RCM) at the time of bioprosthetic tricuspid valve replacement (TVR) and analyze associated risk factors and outcomes. MethodsThis study involved adult patients who underwent TVR with a bioprosthesis at our institution between 2012 and 2022. Bioprosthetic cusp motion was analyzed de novo through a detailed review of intraoperative transesophageal echocardiograms (TEE). Two models of porcine valves were implanted: the Medtronic Hancock II bioprosthesis and the St Jude Medical Epic bioprosthesis. ResultsAmong the 476 patients who met the inclusion criteria, RCM was identified on immediate post-bypass TEE in 150 (31.5%); there was complete immobility of the cusp in 63 patients (13.2%) and limited movement of a cusp in 87 patients (18.3%). In a multivariable logistic regression analysis, the Hancock II model (odds ratio [OR], 6.15; P < .001), a larger orifice area (per IQR increase: OR, 1.58; P = .017), a smaller body surface area (per IQR increase: OR, .68; P = .040), and a lower ejection fraction (per IQR increase: OR, .60; P = .033) were independently associated with having RCM. Cox regression adjusting for 15 covariates revealed that RCM at the time of TVR was independently associated with an increased risk of mortality (hazard ratio, 1.35; P = .049). ConclusionsThis study revealed a high incidence of RCM in bioprosthetic valves in the tricuspid position detected shortly postimplantation, which was associated with increased late mortality. To reduce the probability of RCM, it is important to select the appropriate prosthesis model and size, particularly in small patients.

Failed bioprosthetic tricuspid valve replacement treated with transcatheter valve for valve repair

Tricuspid bioprosthetic valve failure may lead to right-sided heart failure and is traditionally managed with surgical valve replacement. However, the substantial mortality risk associated with reoperation for failed tricuspid bioprosthesis prompts the need for less invasive alternatives. Transcatheter valve-in-valve (TViV) implantation presents a promising minimally invasive option for patients with failing bioprosthetic valves. This case involves a 32-year-old man with a history of recurrent failed bioprosthetic tricuspid valves who underwent successful percutaneous TViV implantation using a 29 mm Edwards Sapien S3 valve, resulting in marked clinical and hemodynamic improvement. This case contributes essential insights to the limited literature on TViV in the tricuspid position, particularly in patients with complex surgical histories. The high procedural success rate and substantial improvement in valve function underscore the potential of TViV as an effective alternative to surgical replacement for failed tricuspid bioprosthetic valves. Keywords: Transcatheter tricuspid valve replacement; tricuspid valve-in-valve; bioprosthetic tricuspid valve; tricuspid valve stenosis

Thrombosis of Prosthetic Tricuspid Valve During Veno-Arterial Extracorporeal Membrane Oxygenation Support: A Case Report

Extracorporeal membrane oxygenation (ECMO) is frequently used for severe postcardiotomy cardiogenic shock in patients with bioprosthetic valves. Acute prosthetic valve thrombosis (PVT) is a rare complication after valve replacement surgery and significantly increases morbidity and mortality. Patients who develop PVT on ECMO could significantly influence the long-term durability of the bioprosthetic valves. However, previous studies only analyzed risk factor and treatment of the mitral valve thrombosis during ECMO support. The mechanism of thrombosis on the tricuspid valve was still unknown. Here we describe the symptoms and treatment of a valve replacement patient who developed bioprosthetic tricuspid valve thrombosis during veno-arterial extracorporeal membrane oxygenation (VA-ECMO). Meanwhile, the patient’s mechanical prosthetic mitral valve functioned normally. An emergency re-do tricuspid prosthesis replacement was performed, and the patient finally developed the successful decannulation. At 6 months follow-up, the patient showed asymptomatic and had a reasonable quality of life. The pathophysiology of tricuspid valve thrombosis may be different from the left heart. Our case highlights that the risk of thrombosis associated with a prosthesis in the tricuspid position can be even higher in the setting of VA-ECMO support. In such patients, promoting forward blood flow across the prosthesis and improving levels of anticoagulation may be particularly important.

Transcatheter Aortic Valve Implantation to Treat Degenerated Aortic, Mitral and Tricuspid Bioprosthesis.

Transcatheter aortic valve implantation (TAVI) is now well established as the treatment of choice for patients with native aortic valve stenosis who are high or intermediate risk for surgical aortic valve replacement. Recent data has also supported the use of TAVI in patients at low surgical risk and also in anatomical subsets that were previously felt to be contra-indicated including bicuspid aortic valves and aortic regurgitation. With advancements and refinements in procedural techniques, the application of this technology has now been further expanded to include the management of degenerated bioprosthesis. After the demonstration of feasibility and safety in the management of degenerated aortic bioprosthetic valves, mitral and tricuspid bioprosthetic valve treatment is now also well-established and provides an attractive alternative to performing redo surgery. In this review, we appraise the latest clinical evidence and highlight procedural considerations when utilising TAVI technology in the management of degenerated aortic, mitral or tricuspid prosthesis.

Pulmonary valve replacement for porcelain right ventricular outflow tract following repeated surgical intervention

BackgroundRepeat surgery is common in adult congenital heart disease, and valve-related procedures are the most frequent indication for re-intervention. In these cases, problems such as advanced adhesion, deterioration and calcification of the prosthesis used, progression of cardiac dysfunction, and worsening of the general condition are often observed.Case presentationWe herein report a 43-year-old patient with repaired pulmonary atresia and ventricular septal defect who experienced repeated right heart failure and protein-losing enteropathy after multiple bioprosthetic tricuspid and pulmonary valve replacements. The patient was successfully treated with a fourth pulmonary valve replacement and third tricuspid valve replacement using a mechanical valve. During surgery, peeling off and removing the right ventricular outflow conduit was risky due to dense adhesion to the ascending aorta with extremely severe calcification; thus, the mechanical pulmonary valve was implanted to a more proximal position of the right ventricular outflow tract after removing the leaflet only and leaving the stent of the bioprosthetic valve within the conduit. The right heart failure and protein-losing enteropathy were relieved with this surgery, and the patient has remained in remission for over 5 years.ConclusionAlthough severe adhesion and porcelain-like calcification caused by multiple surgical interventions were a major issue in this case, good surgical results were obtained. This method has a major advantage over conventional pulmonary valve replacement with right ventricle outflow tract reconstruction when the right ventricular outflow tract conduit shows severe adhesion and calcification.

Preliminary Study of a Degenerated Tricuspid Bioprosthetic Valve Implanted via Transcatheter Valve-in-Valve Implantation Guided by 3-Dimensional Printing

BackgroundThe procedures of transcatheter tricuspid valve-in-valve (TTViV) replacement are challenging, and the clinical outcomes are still unclear. Our goal was to report the short- and mid-term clinical outcomes of patients who underwent a TTViV implantation guided by 3-dimensional (3D) printing. MethodsA retrospective analysis was performed on 6 patients who had TTViV implantation from May 2021 to March 2022. The median age was 51 years (range: 18-71 years), and 50.0% of the patients were male. Imaging assessments and 3D printing were performed on all 6 patients before the procedures. The perioperative data were evaluated, and the patients were followed up. ResultsAmong the 6 patients, the etiologies of conditions affecting the tricuspid valves at baseline varied widely, including 1 case of Ebstein anomaly, 2 cases of infective endocarditis, 1 case of ventricular septal defect, and 2 cases of rheumatic heart disease. TTViV implantation was successfully performed in all 6 patients via the femoral vein approach; postoperative tricuspid regurgitation disappeared immediately, and the hemodynamic results were satisfactory. During the follow-up, all patients had significant improvement in symptoms and functional status. ConclusionsTTViV implantation for the treatment of degenerated tricuspid bioprostheses should be considered safe and effective. Multimodal imaging and 3D printing may provide effective guidance for conducting the procedure. Clinical Trial RegistrationClinicalTrials.gov Protocol Registration System (NCT02917980).

Abstract 18974: Transcatheter Tricuspid Valve Replacement in a Symptomatic Bioprosthetic Tricuspid Stenosis Patient With Carcinoid Heart Disease: A Case Report

Background: Patients with carcinoid heart disease are prone to the development of mild to severe tricuspid regurgitation with or without accompanying tricuspid stenosis. We present an interesting case of a patient with bioprosthetic tricuspid valve stenosis secondary to carcinoid heart disease undergoing transcatheter tricuspid valve replacement (TTVR). Case history: The patient is a 64-year-old female with metastatic carcinoid syndrome and subsequent tricuspid valve replacement with 25 mm Magna ease bovine pericardial valve. The surgery was complicated by carcinoid crisis, pneumothorax, and complete heart block. She presented with worsening shortness of breath with exertion. Echocardiography revealed severe tricuspid stenosis associated with a severely dilated right atrium, moderate pulmonary stenosis. Transesophageal echocardiography confirmed carcinoid degeneration of the bioprosthetic tricuspid valve. CT chest and abdomen with contrast showed consistent findings of severe tricuspid stenosis, metastatic carcinoid tumor with new foci in liver, lungs. Ischemic evaluation with angiography revealed normal coronaries. Decision making: The patient was evaluated by the heart team and was considered to be a prohibitive risk patient for redo surgery. We then evaluated her suitability for transcatheter valve replacement, and the patient was felt suitable for undergoing valve-in-valve transcatheter tricuspid valve replacement via the right internal jugular vein approach because of the coaxial alignment of the valve through this route. The patient successfully underwent this procedure with a 26 mm balloon-expandable valve without any complications and is currently in NYHA class I functional status. Conclusion: Carcinoid syndrome can affect bioprosthetic tricuspid valves and transcatheter valve replacement may be advantageous in replacing the affected bioprosthetic valves by reducing morbidity and mortality.

Imaging and guiding intervention for tricuspid valve disorders using 3-dimensional transesophageal echocardiography in pediatric and congenital heart disease.

In the pediatric and congenital heart disease (CHD) population, tricuspid valve (TV) disorders are complex due to the variable TV morphology, its sophisticated interaction with the right ventricle as well as associated congenital and acquired lesions. While surgery is the standard of care for TV dysfunction in this patient population, transcatheter treatment for bioprosthetic TV dysfunction has been performed successfully. Detailed and accurate anatomic assessment of the abnormal TV is essential in the preoperative/preprocedural planning. Three-dimensional transthoracic and 3D transesophageal echocardiography (3DTEE) provides added value to 2-dimensional imaging in the characterization of the TV to guide therapy and 3DTEE serves as an excellent tool for intraoperative assessment and procedural guidance of transcatheter treatment. Notwithstanding advances in imaging and therapy, the timing and indication for intervention for TV disorders in this population are not well defined. In this manuscript, we aim to review the available literature, provide our institutional experience with 3DTEE, and briefly discuss the perceived challenges and future directions in the assessment, surgical planning, and procedural guidance of (1) congenital TV malformations, (2) acquired TV dysfunction from transvenous pacing leads, or following cardiac surgeries, and (3) bioprosthetic TV dysfunction.

PO-05-029 VENTRICULAR PACING IS RELIABLE WITH A SINGLE LEFT VENTRICULAR QUADRIPOLAR LEAD AND A PLUGGED RIGHT VENTRICULAR PORT IN PATIENTS WITH TRICUSPID VALVE REPAIR OR REPLACEMENT

Transvenous ventricular pacing with a lead crossing a repaired or bioprosthetic tricuspid valve (TV) is undesirable due to the potential effect of permanent pacing leads on repaired or replaced TV function. One potential alternative is left ventricular (LV) pacing via the coronary sinus; however, LV pacing leads are associated with higher thresholds, potential for phrenic nerve stimulation, and lead instability requiring revision. While quadripolar LV leads offer improved lead stability and programmability from multiple electrode pair options, only Abbott CRT-P generators allow for sensing from an IS-4 lead without requiring an IS-1 lead plugged into the right ventricular (RV) port. Feasibility and outcomes with this pacing technique have not been previously reported. To study the reliability of LV-only pacing with a quadripolar lead and plugged RV port in patients with tricuspid valve repair or replacement. 10 consecutive patients with prior TV bioprosthesis or repair underwent quadripolar LV lead placement in CS branch veins with plugged RV port and were retrospectively analyzed. Patient demographics, procedure data, interrogation data and need for reprogramming or lead revision were collected over 16 months mean follow-up. Successful implantation an Abbott CRT-P device with LV quadripolar lead with a plugged RV port was achieved in all patients. 5/10 of these cases involved the concomitant extraction of an RV lead. The target branch vein selected was that which would provide the best perceived lead stability, which was the AIV in two patients and MCV in one patient. Implant LV lead thresholds ranged from 0.75V @ 0.4ms to 2.25V @ 0.4ms with little change in follow-up thresholds, which ranged from 0.5V @ 0.4s to 2.25V @ 0.4ms. No patient experienced undersensing or oversensing in follow-up and R waves were greater than 5 mV in all patients. No patients required lead revision and no patients developed a pacing induced cardiomyopathy (drop in LVEF ≤ 10%) with LV only pacing. Durable ventricular pacing utilizing a single quadripolar LV lead and CRT-P generator is feasible when a transvenous RV lead is undesirable. This can be achieved by utilizing a single manufacturer’s CRT-P generator with unique capability of ventricular sensing from the IS-4 port despite plugged RV IS-1 port. This technique is an attractive alternative to standard dual chamber pacing in patients with prior TV repair or bioprosthesis to reduce risk of future valve dysfunction.Tabled 1PatientAgeSexPacing IndicationRelative Contraindication for RV LeadLV Lead Implant VeinLV Sensing at ImplantLV Sensing at Follow-upLV Threshold at ImplantLV Threshold at Follow-upVP %Preimplant LVEFLast Follow-up LVEF169FSND / Paroxysmal AVBTricuspid Repair, annuloplastyMCV10.8mV>12mV[email protected][email protected]<1%60-65%60-65%233MParoxysmal AVBBioprosthetic Tricuspid ValvePosterolateral branch5.1mV7.2mV[email protected][email protected]2%50%64%342MComplete heart blockBioprosthetic Tricuspid ValvePosterior branch>12mV12mV[email protected][email protected]97%>55%>55%465FSinus node dysfunctionTricuspid Repair, annuloplastyAIV>12mV12mV[email protected][email protected]<1%35-40%35-40%526FComplete heart blockTricuspid Repair, annuloplastyAnterolateral branchNone at VVI 30None at VVI 30[email protected][email protected]92%50%51%669FComplete heart blockSevere TR, Anticipated Tricuspid ClipAIV11.4mV>12mV[email protected][email protected]98%>55%>55%765FSinus node dysfunctionTricuspid Repair, annuloplastyPosterolateral branch8.3mV7mV[email protected][email protected]4%55-60%58%831MComplete heart blockBioprosthetic Tricuspid ValvePosterior branchNone at VVI 30None at VVI 30[email protected][email protected]91%>55%58%957FComplete heart blockBioprosthetic Tricuspid ValveAnterolateral branch12mVNone at VVI 30[email protected][email protected]99%59%56%1057MComplete heart blockBioprosthetic Tricuspid ValvePosterolateral branchNone at VVI 30None at VVI 30[email protected][email protected]98%55-60%55-60% Open table in a new tab

The Role of Transthoracic Echocardiography for Assessment of Mortality in Patients with Carcinoid Heart Disease Undergoing Valve Replacement

Patients with carcinoid heart disease (CHD) are referred for valve replacement if they have severe symptomatic disease or evidence of right ventricular (RV) failure and an anticipated survival of at least 12 months. Data are lacking, however, on the role of transthoracic echocardiography in predicting outcomes. We carried out a retrospective, single-centre cohort study of patients with a biopsy-confirmed neuroendocrine tumour (NET) and CHD undergoing valve replacement for severe valve disease and symptoms of right heart failure. The aim was to identify factors associated with postoperative mortality, both within one year of surgery and during long-term follow-up. Of 88 patients with NET, 49 were treated surgically (mean age: 64.4 ± 7.6 years; 55% male), of whom 48 had a bioprosthetic tricuspid valve replacement for severe tricuspid regurgitation; 39 patients had a pulmonary valve replacement. Over a median potential follow-up of 96 months (interquartile range: 56-125), there were 37 deaths, with 30-day and one-year mortality of 14% (n = 7) and 39% (n = 19), respectively. A significant relationship between RV size and one-year mortality was observed, with 57% of those with severe RV dilatation dying within a year of surgery, compared to 33% in those with normal RV size (p = 0.039). This difference remained significant in the time-to-event analysis of long-term survival (p = 0.008). RV size was found to reduce significantly with surgery (p < 0.001). Those with persisting RV dilatation (p = 0.007) or worse RV function (p = 0.001) on postoperative echocardiography had significantly shorter long-term survival. In this single-centre retrospective study of patients undergoing surgery for CHD, increasingly severe RV dilatation on preoperative echocardiography predicted adverse outcomes, yielding a doubling of the one-year mortality rate relative to normal RV size. These data support the possibility that early surgery might deliver greater long-term benefits in this patient cohort.

Early and long-term outcomes of bioprosthetic versus mechanical tricuspid valve replacement: A nationwide population-based study

ObjectivesWe compared early and long-term clinical outcomes of bioprosthetic versus mechanical tricuspid valve replacement in a nationwide study based on the database from the National Health Insurance Service. MethodsOf 1425 patients who underwent tricuspid valve replacement from 2003 to 2018, 1241 patients were enrolled after excluding retricuspid valve replacement, complex congenital heart disease, Ebstein anomaly, and age less than 18 years at operation. Bioprostheses (group B) and mechanical prostheses (group M) were used in 562 patients (45.3%) and 679 patients (54.7%), respectively. The median follow-up duration was 5.6 years. Propensity score matching was performed. Subgroup analysis was performed in patients aged 50 to 65 years. ResultsThere was no difference in operative mortality or postoperative complications between the groups. All-cause mortality was higher in group B (7.8 vs 4.6 per 100 patient-years, hazard ratio, 1.75, 95% confidence interval, 1.33-2.30, P < .001). The cumulative incidence of stroke was higher in group M (hazard ratio, 0.65, 95% confidence interval, 0.43-0.99, P = .043), whereas the cumulative incidence of reoperation was higher in group B (hazard ratio, 4.20, 95% confidence interval, 1.53-11.54, P = .005). In terms of the age-dependent hazard of all-cause mortality, group B demonstrated a higher hazard than group M below the age of 75 years, and it was statistically significant between 54 and 65 years of age. In the subgroup analysis, all-cause mortality was also higher in group B. ConclusionsMechanical tricuspid valve replacement demonstrated higher long-term survival than bioprosthetic tricuspid valve replacement. In particular, mechanical tricuspid valve replacement showed significantly higher overall survival between 54 and 65 years of age.

Long-Term Outcomes of Bioprosthetic and Mechanical Tricuspid Valve Replacement after Left-Sided Valves Surgery.

This study aimed to show the outcomes of isolated tricuspid valve replacement (ITVR) after left-sided valve surgery (LSVS). Patients who underwent ITVR after LSVS were divided into bioprosthetic tricuspid valve (BTV) and mechanical tricuspid valve (MTV) groups. Clinical data were collected and analyzed between groups. 101 patients were divided into BTV (n = 46) and MTV (n = 55) groups. The mean ages of the BTV and MTV groups were 63.4 ± 8.9 and 52.4 ± 7.6 years, respectively (P <0.01). There was no significant difference in 30-day mortality (BTV 10.9% vs. MTV 5.5%), early postoperative complications, and long-term tricuspid valve (TV)-related adverse events between these two groups. New-onset renal insufficiency was an independent risk factor for early mortality. Survival rates in the BTV group were 94.8% ± 3.6%, 86.5% ± 6.5%, and 54.2% ± 17.6% and in the MTV group were 96.0% ± 2.8%, 79.0% ± 7.4%, and 59.4% ± 14.8% at 1, 5, and 10 years, respectively (P = 0.826). The TV prosthesis selection in ITVR after LSVS seems to not affect 30-day mortality and early postoperative complications. Long-term survival and the occurrence of TV-related events were also comparable between these two groups.

489 A RARE CASE OF LEAD EXTRACTION

Abstract Aims Poor data exist about the leadless PM implantation through a bioprosthetic tricuspid valve. Bioprosthetic tricuspid valve has traditionally represented a relative contraindication to transvenous right ventricular pacing for possible tricuspid bioprosthetic valve damage and dysfunction. Therefore, epicardial pacing is usually preferred to transvenous right pacing through a bioprosthetic tricuspid valve for the deleterious effect of permanent pacing leads on tricuspid bioprosthetic valve function and regurgitation. Methods Our case focuses on a 62-year-old woman with mechanical mitral and biological tricuspid prosthesis due to rheumatic disease since 2007 and with a PM-DDDR for a postsurgical complete atrioventricular block. A lead was implanted in right atrium while another lead was implanted in the coronary sinus (CS) instead of in the right ventricle following the presence of a biological tricuspid prosthesis. In February 2022, she did a replacement of pacemaker (PM) generator to another hospital due to initial battery depletion. In March she described pain at the device pocket and consequent appearance of pocket infection. For this situation she was admitted to our cardiac department. A transesophageal echocardiography (TEE) was performed and showed normal biventricular size and function (LVEF 55%), normal function of valve prostheses and absence of vegetations both on the valves and atrial lead. Subsequently an angiography was performed and revealed little patency of the anonymous-caval-subclavian left axis. We made a diagnosis of pocket infection and decided to extract leads in March. We proceded through debridement of leads and removal of the PM generator. After placing Spectranetics (Philips) Lead Locking Device n.2 (LLD2) along the 2007 right atrial lead, we removed it through the use of a mechanical extractors (Cook 7-8.5 Fr). Then after placing Spectranetics (Philips)Lead Locking Device E (LLDE), the CS lead was completely removed through the use of a mechanical extractors (Cook 7-8.5 Fr) and specific delivery.The procedure was well tolerated and uneventful. Following the negative result of the post-extraction blood cultures, cultures of lead tips and pocket swab, together with the normalization of inflammation indices (WBC and CRP) and to the end of antibiotic therapy, we decided to reimplant the device.For the presence of valve prostheses and the patient's high infectious risk, we decided to implant a leadless PM. Results At the beginning of April we performed a leadless Micra AV PM implantation through 23-F Micra TPS delivery catheter across a tricuspid bioprosthetic valve in the right ventricular apex instead of the middle septum due to implantation difficulties for the concomitant presence of the bioprosthetic valve. The procedure was well tolerated and uneventful too. She was discharged after 72h in good conditions. Conclusions We present an unusual case of lead extraction for the second infection of the device pocket in a patient with mechanical mitral and biological tricuspid prostheses and a lead in coronary sinus for the presence of biological tricuspid prosthesis. Leadless PM implantation represents a new technology by eliminating the risks connected with the presence of the lead across the bioprosthetic valve.

Abstract 12383: Large Field-of-View Intravascular Ultrasound for Peri-Procedural Assessment of Stent Frame Expansion After Transcatheter Heart Valve-in-Valve

Introduction. It is unknown whether large field-of-view intravascular ultrasound (IVUS) can be a valid peri-procedural imaging tool to assess actual expansion of transcatheter heart valve (THV) during valve-in-valve procedures. Hypothesis. To compare % expansion of SAPIEN 3 THV measured with peri-procedural IVUS versus post-procedural cardiac gated contrast multi-slice computer tomography (MSCT). Expansion was defined as actual outer frame area/nominal area x 100%. Methods. Studied were patients with successful valve-in-valve for failed surgical mitral and tricuspid bioprosthetic valves. All underwent peri-procedural IVUS using 10MHz Vision PV035 (Philips North America Corporation, Andover, USA) and post-procedural MSCT (SOMATOM Definition Flash, Dual Source, SIEMENS). IVUS and MSCT (Syngo Via, Siemens, Germany) measurements were off -line and done at 1-mm step along the entire height of SAPIEN 3 THV (height 18, 20 and 22 mm for the Sapien THV 23, 26 and 29 mm, respectively). Results. Five patients (68.8±11.2 years, 3 female) were treated for failed surgical mitral (n=3) and tricuspid (2) bioprosthetic valves using SAPIEN 3 THV size 23mm (n=1), 26mm (n=1), and 29mm (n=3). Mean peri-procedural and pre-discharge residual transvalvular gradient differed substantially (1.9±0.9 vs 7.9±1.1mmHg, p=0.001). In total, 104 corresponding cross-sections of the THVs were measured with both IVUS and MSCT. Actual outer-frame SAPIEN 3 expansion was smaller within the lengths of inflow and mid segment (overlapping the ring) than in the outflow, being substantially smaller than nominal (Fig 1). Overall, there was very good agreement between % expansion of THV stent frame assessed in IVUS and MSCT (93.5%±13.3% vs 96.3%±11.3%; r =0.976 and p&lt;0.001). Conclusions. Peri-procedural use of large field-of-view IVUS offers an accurate insight into actual THV expansion deployed valve-in-valve. Figure 1. % expansion of SAPIEN 3 measured in IVUS and MSCT.

Mid to Long-Term Echocardiographic Follow-up of Patients Undergoing Transcatheter Tricuspid Valve-in-Valve Replacement for Degenerated Bioprosthetic Valves: First Single-Center Report from Iran.

Transcatheter tricuspid valve-in-valve (TTViV) replacement has become an alternative treatment in high-risk patients with bioprosthetic valve degeneration. This is the first report on the mid to long-term echocardiographic findings of patients who underwent TTViV replacement in a cardiac referral center in Iran. Data of 12 patients, consisting of 11 women and 1 man, who underwent TTViV replacement between 2015 and 2021 were reviewed retrospectively. The patients underwent echocardiography before the procedure and at a mean follow-up time of 3.17±1.75 years. All the patients had New York Heart Association (NYHA) function class III/IV before TTViV. Six patients had tricuspid regurgitation, 1 had tricuspid stenosis, and 5 had both. All the patients had successful TTViV. The mean time from the initial valve surgery to TTViV was 6.25±2.45 years. At follow-up, 2 patients had died: 1 due to COVID-19 pneumonia and 1 without a known cause. The remaining 10 patients experienced improvements in the NYHA functional class. Echocardiographic measures showed significant improvements. Transvalvular mean gradient pressure decreased from 7.08±1.98 mm Hg to 5.29±1.63 mm Hg (P=0.028), tricuspid valve pressure half time decreased from 245.00±49.46 ms to 158.64±57.41 ms (P=0.011), tricuspid regurgitation gradient decreased from 39.91±7.31 mm Hg to 26.72±8.99 mm Hg, and left ventricular ejection fraction increased from 47.71±4.70% to 49.79±4.58% (P=0.046). There was no significant paravalvular or transvalvular leakage at follow-up. This is a single-center report on the mid and long-term echocardiographic follow-up of patients after TTViV replacement. Our study showed that TTViV was a safe and efficient method in treating high-risk patients with degenerated bioprosthetic tricuspid valves and had favorable echocardiographic and clinical results.

CANDIDA ALBICANS AS A CAUSE OF PACEMAKER LEAD ENDOCARDITIS : A CASE REPORT AND REVIEW OF THE LITERATURE

CANDIDA ALBICANS AS A CAUSE OF PACEMAKER LEAD ENDOCARDITIS : A CASE REPORT AND REVIEW OF THE LITERATURE

Transcatheter tricuspid valve-in-valve implantation with bioprosthetic balloon expandable valve.

This study was conducted to evaluate the outcome of the transcatheter valve-in-valve implantation for degenerated tricuspid bioprosthetic valves with transcatheter aortic valves. This retrospective study enrolled all consecutive patients who were considered high risk for reoperations by the heart team and who underwent transcatheter valve-in-valve implantation for degenerated tricuspid bioprosthetic valves in Tehran Heart Center, Tehran, Iran. All the procedures were performed via the transfemoral venous route under echocardiography and fluoroscopy guidance with Edwards SAPIEN transcatheter heart valves (Edwards Lifesciences, Irvine, CA). Ten patients underwent successful transcatheter valve-in-valve implantation in the tricuspid position without any major complications or need for emergency surgical interventions. The mean age was 54.1 ± 17.1years, and 8 patients were female. The median follow-up was 19.5months (16-32.25 mon). The mean period between the last tricuspid valve replacement and transcatheter valve-in-valve implantation was 4.9 ± 2.2years. The bioprosthetic valves were Hancock in three patients, Mosaic in the other three patients, and Biocor, Pericarbon, Perimount, and Epic in the other patients. After the procedure, the clinical and functional status improved significantly in all the patients. The mean transvalvular gradient decreased from 6.75 ± 2.66mm Hg to 2.85 ± 0.89 (P < 0.001), and the postoperative tricuspid regurgitation severity decreased significantly in almost all the patients. The hospitalization period after the procedure was 4.4 ± 1.7days. In high-risk patients, transcatheter valve-in-valve implantation seems to be a safe and minimally invasive alternative to reoperations for degenerated tricuspid bioprosthetic valves.