PMC5412621_01
Preprocedure transesophageal echocardiogram. A transesophageal echocardiography long-axis view of the failing bioprosthetic tricuspid valve with evidence of severe regurgitation.
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The degenerating tricuspid bioprosthetic valve showed severe regurgitation and moderate stenosis, with a mean transvalvular gradient of 8.4 mm Hg (Figure 1). A 29-mm Edwards SAPIEN XT (Edwards Lifesciences, Irvine, CA) transcatheter valve was implanted with fluoroscopic and TEE guidance inside the failed tricuspid bioprosthesis (Figures 2A and 2B and Online Data Supplement 1A). Fluoroscopy showed a marked reduction in the heart-synchronous swinging movements of the right ventricular pacing lead (Figures 2C and 2D and Online Data Supplements 1B and 1C).
Valve-in-valve tricuspid valve replacement. A, B: Right anterior oblique (RAO) views during valve-in-valve implantation. A 29-mm SAPIEN XT valve implanted inside a Carpentier-Edwards, porcine, 31-mm valve. C, D: Post-valve deployment cinefluoroscopy demonstrates that the RV pacing lead is now sandwiched (white arrows) between the 2 bioprosthetic valves (black arrows: old Carpentier-Edwards valve; dashed arrows: new Edwards SAPIEN XT valve); C: Left anterior oblique view (LAO). D: Right anterior oblique view (RAO). E: Postimplantation hemodynamic recordings show disappearance of the prominent right atrial v-wave and only a minimal residual diastolic transvalvular gradient of 2-3 mmHg.
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A 29-mm Edwards SAPIEN XT (Edwards Lifesciences, Irvine, CA) transcatheter valve was implanted with fluoroscopic and TEE guidance inside the failed tricuspid bioprosthesis (Figures 2A and 2B and Online Data Supplement 1A). Valve deployment was performed under rapid right ventricular pacing at a rate of 180 beats per minute by controlling the previously implanted pacemaker (Figure 2B). There was an excellent hemodynamic result (Figure 2E) with a residual transvalvular gradient of 2 mm Hg and no evidence of any intra- or paravalvular leak (Figure 2E). The total fluoroscopy time was 34 minutes. Fluoroscopy showed a marked reduction in the heart-synchronous swinging movements of the right ventricular pacing lead (Figures 2C and 2D and Online Data Supplements 1B and 1C).
Results of pacemaker interrogation 6 months post valve-in-valve replacement.
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Table 1 and Figure 3. There was a slight increase in the ventricular pacing threshold at 6 months.