Abstract
Failure of tricuspid annuloplasty for tricuspid regurgitation (TR) is not uncommon, with transcatheter approaches now used for patients with recurrent TR. A 48-year-old woman with rheumatic mitral valve disease and secondary TR (status post surgical repair) presented with recurrence of severe TR after 6 years. She underwent an attempted tricuspid transcatheter valve-in-ring (TVIR) at an outside institution that was complicated by valve migration and recurrent right-sided heart failure exacerbations. She underwent a redo TVIR procedure at our institution successfully. Both surgical and transcatheter approaches for TR are feasible, depending on patient-specific characteristics. A thorough understanding of normal tricuspid valve anatomy is essential to minimize operative complications and to perform transcatheter interventions successfully. This case supports redo TVIR as a useful alternative to surgery following initial TVIR complications when redo surgery is deemed prohibitive secondary to patient characteristics and a high risk of intraoperative mortality.
Key Words: acute heart failure, echocardiography, rheumatic heart disease, tricuspid valve, valve repair
Visual Summary
History of Presentation
A 48-year-old woman presented to an outside hospital with progressively worsening dyspnea on exertion, fatigue, and lower extremity swelling. She was found to have acute decompensated heart failure and was transferred to our institution (Memorial Regional Medical Center, Richmond, VA) for further management. Her vital signs on admission were notable for an oxygen saturation of 92% on 3 L of oxygen. Physical examination revealed a 3/6 holosystolic heart murmur in the subxiphoid region with jugular venous pressure 12 cm H₂O above the sternal angle. Lungs were clear to auscultation with normal capillary refill, although 4+ pitting edema was noted in the bilateral lower extremities.
Take-Home Messages
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Transcatheter techniques represent a useful alternative treatment strategy following TR recurrence after surgical annuloplasty when redo surgery is deemed prohibitive secondary to patient characteristics and a high risk of intraoperative mortality.
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A thorough understanding of normal tricuspid valve anatomy is crucial for grasping the pathophysiology of tricuspid leaflet coaptation failure and is essential as interventions shift toward transcatheter solutions for TR.
Past Medical History
The patient had known severe rheumatic mitral valve stenosis (she had undergone surgical repair with a 29-mm Edwards Magna valve [Edwards Lifesciences]), tricuspid regurgitation (TR) (secondary to severe mitral stenosis; she had undergone surgical repair with a 26-mm Edwards Classic Ring [rigid, Edwards Lifesciences]), hypertension, pulmonary hypertension (group II), nonischemic cardiomyopathy (left ventricular ejection fraction [LVEF] 30%), cardiac cirrhosis (Child-Pugh class B), and diabetes mellitus type 2. Six years after her surgical valve repair, the patient’s disease progressed and led to recurrent severe TR prompting an attempted tricuspid transcatheter valve-in-ring (TVIR) with an Edwards SAPIEN Ultra (23 mm) valve (Edwards Lifesciences) at an outside institution. Unfortunately, during the attempted TVIR deployment, the valve migrated next to the ring and caused further deterioration of her severe TR and impingement of her automatic implantable cardioverter-defibrillator (AICD) lead (Figure 1, Video 1).
Figure 1.
Attempted Transcatheter Valve-in-Ring at an Outside Institution
Mitral valve replacement noted on the right side of the image with the tricuspid annuloplasty ring noted on the left side of the image. Attempted transcatheter valve-in-ring (malpositioned transcatheter heart valve [THV]) with a 23-mm Edwards SAPIEN valve lodged between the automatic implantable cardioverter-defibrillator (AICD) lead and the mouth of the tricuspid ring in the center of the image.
She presented to the outside institution’s emergency department 1 week later in complete heart block secondary to lead fracture and urgently had a new AICD lead placement. During this hospitalization, she underwent diuresis with plans for outpatient follow-up. Unfortunately, she had 4 hospitalizations for recurrent decompensated right-sided heart failure (RHF) believed to be in the setting of her malpositioned transcatheter heart valve (THV). During her latest exacerbation, she was transferred to our institution for further management and consideration for advanced therapies.
Differential Diagnosis
The differential diagnosis included non–group II pulmonary hypertension, mitral regurgitation, pulmonary embolism, and AICD thrombus.
Investigations
The presentation electrocardiogram showed an atrioventricular paced rhythm. Laboratory test results showed a high-sensitivity troponin level of 15 ng/L (reference range, 0-51 ng/L) with N-terminal pro–B-type natriuretic peptide elevation to 1,392 pg/mL (reference range, <125 pg/mL). The patient underwent a transthoracic echocardiogram (TTE), showing an LVEF of 20% with severe TR and no stenosis or regurgitation of the mitral valve. Transesophageal echocardiogram (TEE) showed that the AICD lead was impinged behind the malpositioned THV (Figure 2, Video 2), with torrential TR between the malpositioned THV and the tricuspid annuloplasty ring (Figure 3, Video 3). The patient also underwent right-sided heart catheterization showing a pulmonary capillary wedge pressure of 20 mm Hg, a pulmonary artery pressure of 54/30 (42) mm Hg, a right ventricular pressure of 55/7 (17) mm Hg, large V waves with a mean right atrial pressure of 24 mm Hg, cardiac output of 3.6 L/min, and a cardiac index of 1.9 L/min/m2. Preoperative computed tomography and 3-dimensional reconstruction showed the original tricuspid ring in place with the malpositioned THV tilted toward the coronary sinus (Figures 4 and 5, Video 4).
Figure 2.
Initial Transesophageal Echocardiogram Performed at Our Institution
A transesophageal echocardiogram showing the automatic implantable cardioverter-defibrillator (AICD) lead impinged behind the malpositioned transcatheter heart valve (THV).
Figure 3.
Preoperative Doppler Image
Triangular signal confirming severe tricuspid regurgitation (TR) with a rapid rise in right atrial pressure secondary to regurgitant flow. MaxPG = maximum pressure gradient; Vmax = maximum velocity.
Figure 4.
Preoperative Computed Tomography
Preoperative computed tomography showing the malpositioned transcatheter heart valve and measurement of the tricuspid annuloplasty ring. Avg = average; Max = maximum; Min = minimum.
Figure 5.
3-Dimensional Reconstruction of Chest Computed Tomography
A chest computed tomography 3-dimensionalreconstruction showing the original tricuspid ring in place with the malpositioned transcatheter heart valve (THV) between the annuloplasty ring and interatrial septum tilted toward the coronary sinus.
Management
The patient’s condition was optimized with diuretic agents and dobutamine, with ongoing evaluation by the multidisciplinary heart team. Given her numerous comorbidities, high bleeding risk, severe RHF, and underlying cardiac cirrhosis, a salvage redo TVIR was chosen as the best option (Table 1).
Table 1.
Equipment List
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| Access |
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| Tricuspid transcatheter valve device |
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During the procedure, access was obtained through the right common femoral vein (CFV) and the right internal jugular vein (IJV) under ultrasound and fluoroscopic guidance. A 14-F sheath was placed in the right CFV, and a 24-F sheath was placed in the right IJV, with preclosure of both sites performed with Perclose devices (Abbott). The patient was fully anticoagulated with heparin. The previously malpositioned THV was crossed using an Agilis steerable catheter (Abbott) and a pigtail catheter from the CFV site. A Safari wire (Boston Scientific) was then placed in the right ventricle so that a 22-mm True Balloon (Bard) could be advanced over the wire to stabilize the malpositioned THV in hopes of avoiding further migration. The tricuspid annulus was crossed from the right IJV site by using a pigtail catheter, and a second Safari wire was placed in the right ventricle. The Edwards SAPIEN Resilia 23-mm valve (loaded on the Commander delivery system [Edwards Lifesciences]) was then advanced under fluoroscopic guidance from the right IJV (Figure 6, Video 5).
Figure 6.
Positioning of the New Transcatheter Valve-in-Ring
Safari wire #1 (through right common femoral vein [CFV] access) crossing the malpositioned THV and Safari wire #2 (through right internal jugular [IJ] vein access) crossing the tricuspid annuloplasty ring. The new transcatheter heart valve (THV) was advanced under fluoroscopic guidance. AICD = automatic implantable cardioverter-defibrillator.
The True Ballon was inflated during crossing to avoid any migration or interaction with the malpositioned THV. By using multiple views, the new Edwards Resilia 23-mm valve was positioned, with successful deployment without the need for rapid pacing (Figure 7, Videos 6 and 7). Rapid pacing was not used during this case because the right side of the heart operates under lower pressures gradients with low-velocity inflow. Further, the patient had underlying RHF, so dropping her cardiac output would likely compromise her hemodynamic stability even more. Instead of rapid pacing, a balloon anchoring technique was used, as discussed earlier.
Figure 7.
Successful TVIR Inflation
Postinflation image with a new SAPIEN valve (Edwards Lifesciences) appropriately placed within the tricuspid annuloplasty ring. The previous malpositioned transcatheter heart valve (THV; oval structure) can be appreciated to the right of the newly implanted SAPIEN valve. TVIR = transcatheter valve-in-ring.
Intraoperative TEE showed trace TR of the previous THV with no jets in between the 2 THVs (Videos 8 and 9). The patient did well postoperatively and was started on systemic anticoagulation with apixaban.
Outcome and Follow-Up
A 1-month follow-up TTE showed no significant TR (Video 10), with a mean gradient of 3.35 mm Hg (Figure 8). She has had no repeat hospitalizations since the completion of this procedure.
Figure 8.
Postoperative Transthoracic Echocardiogram
A 1-month postoperative thoracic echocardiogram with a mean pressure gradient (PGmean) of 3.35 mm Hg. PGmax = maximum pressure gradient; Vmax = maximum velocity; Vmean = mean velocity; VTI = velocity time integral.
Discussion
We describe the case of a patient with known rheumatic mitral valve stenosis and secondary TR (status post surgical repair), with recurrence of severe TR and recurrent RHF decompensations, ultimately necessitating advanced transcatheter interventions. Although the incidence of rheumatic mitral stenosis remains low in high-income countries and has slowly declined in low- to middle-income countries, it remains a major cause of valvular disease worldwide.1 Rheumatic mitral stenosis is much more common in female patients (∼80%), and the clinical presentation tends to vary by regional prevalence.1 Our patient was from a low-income rural part of the United States, categorized as a region of low disease prevalence. These patients tend to present at older ages (50-70 years), decades after their initial rheumatic fever episode, with calcified fibrotic leaflets, commissural fusion, and subvalvular involvement.1
TR secondary to left-sided valvular heart disease (secondary TR) is commonly observed as a result of the hemodynamic consequences imposed on the left atrium, the pulmonary vasculature, and subsequently the right atrium, which ultimately lead to tricuspid annular dilatation. Specifically, moderate or severe TR secondary to severe mitral stenosis can be seen in approximately 30% of patients with severe mitral stenosis.2 Secondary TR promotes volume overload, increased wall stress on the right ventricle, and cardiac remodeling that ultimately leads to an increase in heart failure symptoms and mortality.3 When deciding on tricuspid valve interventions, numerous factors must be accounted for, including the patient’s clinical characteristics, disease severity, concomitant end-organ function, and specific anatomical considerations.3
Currently, both surgical and transcatheter approaches exist for severe TR, each with distinct indications and considerations. The surgical approach has traditionally been preferred for severe TR, specifically when there is a need for concomitant left-sided valvular surgery, given the high perioperative mortality associated with reoperation for isolated TR.1 The transcatheter approach is a newer, emerging field that has shown promise, particularly for high-risk surgical candidates. Given our patient’s numerous comorbidities and prohibitive surgical risk, the decision was made to pursue a salvage redo TVIR.
The complex, variable anatomy of the right side of the heart and the limited maneuverability of catheters are 2 considerations that make TVIR challenging. Specifically, the protuberant crista terminalis, the limbus of the fossa ovalis, the Eustachian valve, and the Thebesian valve can act as physical barriers and are possible sites of entanglement for transcatheter devices.4 Further, the retrosternal location of the tricuspid valve makes intraoperative guidance by TEE more challenging compared with mitral valve interventions. The tricuspid annulus also contains less collagen, is more flexible, and is rarely calcified, thus making implantation fixation a challenge.4
When considering a valve-in-ring, operators must be cautious, given the variations in shape, type, and rigidity of prosthetic rings. In this specific case, the patient had a rigid Edwards Classic Ring. Rigid rings typically have noncircular geometry that does not conform well to the more circular design of transcatheter valves. Sometimes, predilation can help make the ring more pliable. In addition, rigid rings lack the flexibility to accommodate changes in annulus shape during valve deployment. In some instances, overlapping or uneven portions of the ring can cause the THV to deploy unevenly, increasing the risk of migration.
Semirigid rings and flexible rings have unique benefits and challenges when attempting a TVIR. The semirigid rings provide a better balance of stability and flexibility, thus decreasing the potential for geometric mismatch with THVs. The downside compared with rigid rings is that they may provide less annular stability, thereby increasing the risk of deformation over time. Flexible rings maintain natural annular motion and can provide a more anatomically compatible substrate for TVIR; however, they do not provide as stable a platform to deploy the valve, and this instability makes valve embolization or migration more likely.
The anatomy of the tricuspid valve, the adjacent structures, and any previous hardware must be considered in the preoperative phase. The annuloplasty rings are often distorted, leading to an incomplete seal following valve implantation, particularly in the area abutting the septum.5 Consulting with a multidisciplinary heart team is essential to ensure thorough preoperative planning and to establish effective contingency strategies for any intraoperative challenges that may arise. Our patient provided informed consent for this report, and Institutional Review Board review was not required because this was a single case report.
Conclusions
Treatment for severe TR is nuanced, with both surgical and transcatheter approaches available on the basis of the patient’s clinical picture. For patients with numerous comorbidities precluding surgical intervention, transcatheter approaches can provide an alternative treatment strategy. There are many risks associated with TVIR, including malpositioning or migration of the valve and bioprosthesis failure. This case highlights the feasibility of a repeat TVIR following a previously malpositioned THV placement with ongoing torrential TR and demonstrates the utility of transcatheter approaches as an alternative treatment strategy for comorbid and anatomically challenging patients.
Visual Summary.
Timeline of Events
| Date | Events |
|---|---|
| Year 1 | The patient underwent surgical repair of her severe mitral stenosis and had a tricuspid annuloplasty ring placed for secondary tricuspid regurgitation (TR) at an outside institution. |
| Years 1-6 | The patient had been doing well clinically following the procedures. |
| Year 6 | The patient presented to an outside institution with recurrent severe TR in the setting of right-sided heart failure (RHF). She had an attempted transcatheter valve-in-ring (TVIR) procedure performed at this time that migrated on deployment, resulting in further deterioration of her severe TR and impingement of her automatic implantable cardioverter-defibrillator (AICD) lead. |
| Year 6 | She presented to the outside institution’s emergency department in complete heart block and immediately had a new AICD lead placement. She was discharged with plans for outpatient follow-up. |
| Year 6 | Following discharge, the patient had 4 admissions for recurrent RHF. During her most recent exacerbation, she was transferred to our institution for further management and consideration of advanced therapies. |
| Year 7 | The patient presented to our institution in decompensated heart failure. |
| Year 7 | The patient’s condition was optimized with diuretic agents and dobutamine, with ongoing evaluation by the multidisciplinary heart team. A sternotomy was deemed too high risk, and a repeat TVIR procedure was chosen as the safest option. |
| Year 7 | A TVIR procedure was successfully performed, with an intraoperative transesophageal echocardiogram showing trace TR of the previous transcatheter heart valve (THV) with no jets in between the 2 THVs. |
| Year 7 | A 1-month follow-up transthoracic echocardiogram showed no significant TR with a mean gradient of 3.35 mm Hg. She has had no repeat hospitalizations since then. |
Funding Support and Author Disclosures
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
Footnotes
The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the Author Center.
Appendix
For supplemental videos, please see the online version of this paper.
Appendix
Attempted TVIR at Outside Institution
Mitral valve replacement noted on the right side of the video with the tricuspid annuloplasty ring noted on the left side of the video. Attempted transcatheter valve-in-ring (TVIR) with a 23-mm Edwards SAPIEN valve (Edwards Lifesciences) lodged between the automatic implantable cardioverter-defibrillator lead and the mouth of the tricuspid ring in the center of the video resulting from migration during deployment
Initial TEE at Our Institution
Transesophageal echocardiogram (TEE) with and without color showing the automatic implantable cardioverter-defibrillator lead impinged behind the malpositioned transcatheter heart valve
Initial TEE With Color Doppler at Our Institution
Torrential tricuspid regurgitation between the malpositioned transcatheter heart valve and the tricuspid annuloplasty ring highlighted with color Doppler
3-Dimensional Reconstruction of Chest CT
A chest computed tomography (CT) 3-dimensional reconstruction showing the original tricuspid ring in place with the malpositioned transcatheter heart valve between the annuloplasty ring and the interatrial septum tilted toward the coronary sinus
Positioning of the New Transcatheter Valve-in-Ring
Safari wire #1 (through right common femoral vein access) crossing the malpositioned transcatheter heart valve and Safari wire #2 (through right internal jugular vein access) crossing the tricuspid annuloplasty ring. The new SAPIEN valve (Edwards Lifesciences) loaded on the Commander delivery system (Edwards Lifesciences) was advanced under fluoroscopic guidance
New SAPIEN Valve Deployment
Slow inflation of the new transcatheter valve-in-ring with no rapid pacing required. The True Balloon (Bard) was kept in the malpositioned transcatheter heart valve in case it moved, with plans for reinflation if necessary
Successful TVIR Inflation
Postinflation films with a new SAPIEN valve (Edwards Lifesciences) appropriately placed within the tricuspid annuloplasty ring. The previous transcatheter heart valve (oval structure) can be appreciated to the right of the newly implanted SAPIEN valve
Postdeployment Intraoperative TEE
Trace tricuspid regurgitation of the previous transcatheter heart valve with no jets in between the 2 transcatheter heart valves
Postdeployment Intraoperative TEE (Color Doppler)
Trace tricuspid regurgitation of the previous transcatheter heart valve with no jets in between the 2 transcatheter heart valves visualized with color Doppler
One-Month Postprocedural TTE
One-month postprocedural transthoracic echocardiogram (TTE) showing no significant tricuspid regurgitation
References
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Associated Data
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Supplementary Materials
Attempted TVIR at Outside Institution
Mitral valve replacement noted on the right side of the video with the tricuspid annuloplasty ring noted on the left side of the video. Attempted transcatheter valve-in-ring (TVIR) with a 23-mm Edwards SAPIEN valve (Edwards Lifesciences) lodged between the automatic implantable cardioverter-defibrillator lead and the mouth of the tricuspid ring in the center of the video resulting from migration during deployment
Initial TEE at Our Institution
Transesophageal echocardiogram (TEE) with and without color showing the automatic implantable cardioverter-defibrillator lead impinged behind the malpositioned transcatheter heart valve
Initial TEE With Color Doppler at Our Institution
Torrential tricuspid regurgitation between the malpositioned transcatheter heart valve and the tricuspid annuloplasty ring highlighted with color Doppler
3-Dimensional Reconstruction of Chest CT
A chest computed tomography (CT) 3-dimensional reconstruction showing the original tricuspid ring in place with the malpositioned transcatheter heart valve between the annuloplasty ring and the interatrial septum tilted toward the coronary sinus
Positioning of the New Transcatheter Valve-in-Ring
Safari wire #1 (through right common femoral vein access) crossing the malpositioned transcatheter heart valve and Safari wire #2 (through right internal jugular vein access) crossing the tricuspid annuloplasty ring. The new SAPIEN valve (Edwards Lifesciences) loaded on the Commander delivery system (Edwards Lifesciences) was advanced under fluoroscopic guidance
New SAPIEN Valve Deployment
Slow inflation of the new transcatheter valve-in-ring with no rapid pacing required. The True Balloon (Bard) was kept in the malpositioned transcatheter heart valve in case it moved, with plans for reinflation if necessary
Successful TVIR Inflation
Postinflation films with a new SAPIEN valve (Edwards Lifesciences) appropriately placed within the tricuspid annuloplasty ring. The previous transcatheter heart valve (oval structure) can be appreciated to the right of the newly implanted SAPIEN valve
Postdeployment Intraoperative TEE
Trace tricuspid regurgitation of the previous transcatheter heart valve with no jets in between the 2 transcatheter heart valves
Postdeployment Intraoperative TEE (Color Doppler)
Trace tricuspid regurgitation of the previous transcatheter heart valve with no jets in between the 2 transcatheter heart valves visualized with color Doppler
One-Month Postprocedural TTE
One-month postprocedural transthoracic echocardiogram (TTE) showing no significant tricuspid regurgitation