Valve-in-Ring Transcatheter Heart Valve for Severe Tricuspid Regurgitation

Abstract

We report the case of a man with recurrent decompensated right-sided heart failure secondary to severe tricuspid regurgitation after tricuspid annuloplasty. He was unfit for repeat surgical intervention and thus was considered for a valve-in-ring transcatheter heart valve. We detail the procedural complexities encountered and our approach to overcoming them. (Level of Difficulty: Advanced.)

Graphical abstract

We report the case of a man with recurrent decompensated right-sided heart failure secondary to severe tricuspid regurgitation after tricuspid…

History of Presentation

The patient, a 74-year-old man, was experiencing frequent decompensations of right-sided heart failure approximately 1 year after undergoing tricuspid valve annuloplasty with a 34-mm Carpentier-Edwards MC3 band (Edwards Lifesciences, Irvine, California) for severe tricuspid regurgitation with right-sided heart failure. The initial mechanism of tricuspid regurgitation was believed to be a combination of functional regurgitation associated with chronic atrial fibrillation and possible leaflet tethering from the right ventricular lead of his permanent pacemaker. Two months after the surgical repair, severe tricuspid regurgitation had returned, and he required frequent, prolonged hospital admissions. The mechanism of early failure of the surgical repair was unclear but may have been related to irreversible right ventricular dilatation and impairment resulting in recurrent functional tricuspid regurgitation.

Learning Objectives

• •Recognize the potential role for THV in treating severe tricuspid regurgitation after annuloplasty.
• •Appreciate the complexities of matching THV sizes to the complex geometry of a repaired tricuspid annulus and the implications of this difficulty for paravalvular regurgitation.
• •Recognize the potential for percutaneous closure of PVL in this setting.

Physical Examination

On examination, the patient was mildly short of breath with a slightly increased respiratory rate of 24 breaths/min and labored breathing. A permanent pacemaker was visible over the left chest wall. Oxygen saturation levels were 95% on room air. He was in atrial fibrillation with pulse rate of 88 beats/min and blood pressure of 120/70 mm Hg. Jugular venous pulsation was present at the angle of his jaw with obvious V waves. He had normal respiratory variation of his jugular venous pressure. Heart sounds were dual with a loud pansystolic murmur heard loudest at the left lower sternal edge and on inspiration. Auscultation of the chest revealed decreased air entry and dullness to percussion at both lung bases, consistent with small bilateral pleural effusions. He had pitting edema up to his mid thighs and some mild sacral edema. Abdominal examination revealed a pulsatile liver but no obvious ascites. Blood analysis was remarkable for hypoalbuminemia at 24 g/l. No significant proteinuria was seen, and fecal examination for a protein-losing enteropathy was negative.

Past Medical History

The patient’s cardiac history included permanent atrial fibrillation with implantation of a permanent pacemaker for tachy-brady syndrome. At the time of tricuspid annuloplasty, the right ventricular lead was changed to a left ventricular lead in an attempt to mitigate tricuspid regurgitation through lead-induced leaflet tethering.

His other medical history included chronic kidney and chronic liver disease, both predominantly attributed to cardiac disease. Baseline cardiac medications included furosemide, spironolactone, and warfarin. At a discussion of this case at a heart team meeting, the patient was deemed to be unfit for further surgical intervention because of significant hypoalbuminemia and progressive right ventricular dilatation and impairment. Therefore, he was offered a transcatheter alternative.

Investigations

Transthoracic echocardiography demonstrated normal left ventricular size with mild-to-moderate impairment of left ventricular systolic function. The right ventricle was dilated with impaired systolic function. Moderate-to-severe biatrial dilatation was seen. Severe tricuspid regurgitation through the tricuspid valve repair was observed (Figure 1).

Figure 1.

Transthoracic Echocardiogram in Apical 4-Chamber View

Color-flow mapping demonstrated severe tricuspid regurgitation despite previous annuloplasty.

A right heart study confirmed the absence of significant left-sided heart disease, pulmonary hypertension, or pericardial constriction (mean pulmonary artery pressure 22 mm Hg; pulmonary capillary wedge pressure 16 mm Hg).

A noncontrast electrocardiography-gated cardiac computed tomographic scan was performed to help model the feasibility of implanting a 29-mm Sapien3 transcatheter heart valve (THV) (Edwards Lifesciences) in the larger 34-mm Carpentier-Edwards MC3 band (Edwards Lifesciences). Because of the elliptical nature and open frame of the MC3 band, the Sapien3 valve would make contact only along the short axis and almost certainly result in a paravalvular leak (PVL) along the long axis.

Management

The valve-in-ring (VIR) procedure was performed with transesophageal echocardiographic guidance with the patient under general anesthesia. Right femoral venous access was obtained with ultrasound guidance and pre-closed with 1 Proglide device (Abbott Vascular, Chicago, Illinois) before insertion of a 16-F E-sheath (Edwards Lifesciences). The tricuspid valve was crossed using a 6-F MP1 catheter and a 0.035-inch J-tip wire, which was then exchanged for a pre-shaped Safari TAVI wire (Boston Scientific) (Figure 2). A 29-mm Sapien3 THV (Edwards Lifesciences) was slowly deployed across the tricuspid annuloplasty ring (Figure 3). Right ventriculography and transesophageal echocardiography demonstrated significant valvular and paravalvular tricuspid regurgitation immediately after deployment (Figure 4). The cause of valvular regurgitation was entrapment of 1 leaflet of the THV (Figure 5), which could not be freed by simple wire or catheter manipulation. A second 29-mm Sapien3 THV was implanted within the original THV (Figure 6) in a slightly more ventricular position to overcome the leaflet entrapment. Transesophageal echocardiography confirmed resolution of tricuspid regurgitation, but moderate PVL persisted (Figure 7). We initially elected to manage the leak conservatively because we believed that the risk of valve embolization during PVL closure might be reduced if we were able to stage the PVL closure at least 1 month after the index procedure. We had previously discussed that if severe PVL occurred after valve implantation, PVL closure would be attempted during the index procedure.

Figure 2.

Fluoroscopy Set-Up Image With Pre-Shaped TAVI Wire Positioned in the Right Ventricle

Note annuloplasty band, left ventricular pacing lead, and abandoned right ventricular pacing lead tip.

Figure 3.

The 29-mm Sapien3 Transcatheter Heart Valve Deployed Within Tricuspid Valve Annuloplasty Ring

Figure 4.

Transesophageal Echocardiogram With Color Compare After Deployment of THV

Significant residual tricuspid regurgitation is seen. THV = transcatheter heart valve.

Figure 5.

3-Dimensional Transesophageal Echocardiogram After Deployment of THV

Entrapment of one of the transcatheter heart valve (THV) leaflets is seen.

Figure 6.

Second THV Deployed Within the First THV

The second THV was implanted within the original THV in a slightly more ventricular position to overcome leaflet entrapment. THV = transcatheter heart valve.

Figure 7.

Resolution of Valvular Tricuspid Regurgitation After Deployment of Second THV

Moderate paravalvular leak persisted. THV = transcatheter heart valve.

Echocardiography performed 6 weeks post-procedure demonstrated severe PVL (Figures 8 and 9). The patient was readmitted to the hospital with decompensated right-sided heart failure, which mandated PVL closure.

Figure 8.

Transthoracic Echocardiogram at 6-Week Follow-Up

Severe paravalvular leak is seen.

Figure 9.

3-Dimensional Transesophageal Echocardiogram at 6-Week Follow-Up

Severe paravalvular leak is seen.

Bifemoral venous access was gained using ultrasound guidance, and the right femoral venous access was pre-closed with 1 Proglide device (Abbott Vascular). An 18-F sheath (Cook Medical, Bloomington, Indiana) was then inserted into the right femoral vein and a 6-F sheath inserted into the left femoral vein. An 8.5-F Agilis (Abbott Vascular) steerable sheath was used to introduce a 0.035-inch angled hydrophilic wire across the defect. The wire was exchanged for a 0.035-inch Amplatzer extrastiff wire. A second Amplatzer extrastiff wire was used as a buddy wire. A 6-F Amplatzer TorqVue (Abbott Vascular) delivery sheath was used to position a total of 4 Amplatzer Vascular PlugIII (Abbott Vascular) devices (2 × 14 mm/5 mm, 1 × 10 mm/5 mm, 1 × 12 mm/5 mm) across the paravalvular defect (Figures 10, 11, and 12). The vascular plugs were released only after all of the devices were in place. Transesophageal echocardiography demonstrated only trivial PVL at completion of the procedure (Figure 13).

Figure 10.

Positioning 4 Vascular Plug Devices Across the Paravalvular Defect

Figure 11.

Positioning 4 Vascular Plug Devices Across the Paravalvular Defect

Figure 12.

Positioning 4 Vascular Plug Devices Across the Paravalvular Defect

Figure 13.

Trivial Residual Paravalvular Leak at Completion of the Second Procedure

Follow-Up

The patient experienced significant symptomatic relief and functional improvement. He remained free from rehospitalization for 6 months.

Discussion

Transcatheter interventions for tricuspid regurgitation have been developing more gradually than transcatheter interventions for aortic and mitral valve pathologies. Accordingly, there has been a slowly increasing volume of data on various transcatheter approaches for tricuspid regurgitation, including implantation of THVs (currently an off-label use of THVs). Only a small number of cases of VIR THV implantation after previous tricuspid annuloplasty have been published (1,2). Few cases worldwide have been performed in tricuspid annuloplasty rings with diameters larger than 32 mm. Our case demonstrates that tricuspid VIR implantation is feasible, although current commercially available THVs would be an imperfect match for the complex ovoid geometry of the tricuspid annulus, leading to inherent PVL. Based on computed tomographic modeling before the procedure, a significant paravalvular defect size was anticipated in our patient’s case. However, our case demonstrates that transcatheter closure of significant PVL may be a safe and effective method of overcoming this hurdle until tailored tricuspid THV solutions become available. PVL closure with plugs is common in the aortic and mitral positions but not in the tricuspid position. The stability of a PVL closure depends on the integrity of the surrounding tissues, making the space between a THV and annuloplasty ring ideally suited to closure with vascular plugs.

Conclusions

THV implantation is feasible within tricuspid valve annuloplasty rings, although significant PVL highlights the difficulty encountered with matching prostheses to the complex geometry of tricuspid annuli. Further evaluation with larger patient cohorts would be required to determine safety, efficacy, and economic data.