Transcatheter Tricuspid Valve Replacement in Orthotopic Heart Transplant

J INVASIVE CARDIOL 2017;29(6):E75-E76.

Key words: transcatheter valve replacement, transfemoral

A 49-year-old male with familial cardiomyopathy who underwent orthotopic heart transplant (OHT) at the age of 34 years¹ developed progressive tricuspid regurgitation and underwent tricuspid valve replacement with a 31 mm Perimount bioprosthesis (Edwards Lifesciences). Seven years later, he developed severe tricuspid bioprosthetic stenosis. A balloon valvuloplasty transiently improved gradients, but stenosis recurred 2 years later (Figure 1A). A subsequent attempt at valvuloplasty yielded suboptimal reduction in gradients and led to the development of tricuspid regurgitation. The patient was offered transcatheter tricuspid valve replacement (TTVR) to avoid what would have been his fourth sternotomy.

The procedure was performed via femoral approach. A Josephson Curve Viking left ventricular pacing lead (Boston Scientific) was placed in the left ventricle retrogradely via the aortic valve (Figure 1C). A 14 Fr Agilis Sheath (St. Jude) was required to direct a balloon-tipped catheter via the stenosed tricuspid bioprosthesis due to the massively enlarged right atrium. An 0.018˝ guidewire was used to exchange for a multipurpose guide catheter that was used to deliver an Amplatz SuperStiff guidewire (Boston Scientific), over which balloon valvuloplasty was performed with a 24 mm balloon (Figure 1C). This was followed by placement of a 29 mm Sapien 3 valve (Edwards Lifesciences) in reversed configuration under rapid left ventricular pacing with excellent placement (Figures 1D, 1G, and 1H). A second balloon inflation was performed to flare the valve base in the right atrium (Figure 1E), achieving a 2 mm Hg residual gradient and no regurgitation (Figure 1B). On follow-up, the patient has been asymptomatic and hemodynamically stable, without recurrence of tricuspid stenosis or regurgitation. 

During TTVR, left ventricular pacing should be considered for added stability during deployment. Placing the stiff guidewire in the pulmonary artery can further stabilize the “guidewire rail” while delivering the prosthesis (Figure 1C) without risk of perforation of the thin right ventricle free wall (Figure 1D). TTVR in patients with OHT can be a valuable approach to prevent further open-heart surgeries, which carry added morbidity and mortality.^2,3    

References

1.    Rana G, Shih J, Kakouros N. Percutaneous transcatheter balloon valvuloplasty for bioprosthetic tricuspid valve stenosis in a patient with orthotopic heart transplant. J Invasive Cardiol. 2015;27:E40-E41.

2.    George TJ, Beaty CA, Ewald GA, et al. Reoperative sternotomy is associated with increased mortality after heart transplantation. Ann Thorac Surg. 2012;94:2025-2032. Epub 2012 Sep 7.

3.    Roselli EE. Reoperative cardiac surgery: challenges and outcomes. Tex Heart Inst J. 2011;38:669-671.

From the University of Massachusetts Medical School, Worcester, Massachusetts.

Manuscript accepted December 16, 2016.

Address for correspondence: Nikolaos Kakouros, MD, PhD, University of Massachusetts Medical School, 55 Lake Ave North, Worcester, MA 01655. Email: nikolaos.kakouros@umassmed.edu