Mid-Term Valve-Related Outcomes After Transcatheter Tricuspid Valve-in-Valve or Valve-in-Ring Replacement

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

OBJECTIVES

We 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.

METHODS

Of 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.

RESULTS

There 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.

CONCLUSIONS

Mechanical 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.

The Tricuspid Valve: A Review of Pathology, Imaging, and Current Treatment Options: A Scientific Statement From the American Heart Association

Tricuspid valve disease is an often underrecognized clinical problem that is associated with significant morbidity and mortality. Unfortunately, patients will often present late in their disease course with severe right-sided heart failure, pulmonary hypertension, and life-limiting symptoms that have few durable treatment options. Traditionally, the only treatment for tricuspid valve disease has been medical therapy or surgery; however, there have been increasing interest and success with the use of transcatheter tricuspid valve therapies over the past several years to treat patients with previously limited therapeutic options. The tricuspid valve is complex anatomically, lying adjacent to important anatomic structures such as the right coronary artery and the atrioventricular node, and is the passageway for permanent pacemaker leads into the right ventricle. In addition, the mechanism of tricuspid pathology varies widely between patients, which can be due to primary, secondary, or a combination of causes, meaning that it is not possible for 1 type of device to be suitable for treatment of all cases of tricuspid valve disease. To best visualize the pathology, several modalities of advanced cardiac imaging are often required, including transthoracic echocardiography, transesophageal echocardiography, cardiac computed tomography, and cardiac magnetic resonance imaging, to best visualize the pathology. This detailed imaging provides important information for choosing the ideal transcatheter treatment options for patients with tricuspid valve disease, taking into account the need for the lifetime management of the patient. This review highlights the important background, anatomic considerations, therapeutic options, and future directions with regard to treatment of tricuspid valve disease.

Transcatheter Intervention for Inoperable Tricuspid Surgical Prosthesis Dysfunction: Minimally Invasive Approach to Mitigate Heart Failure

What is the efficacy and safety of transcatheter tricuspid valve-in-valve implantation for patients with inoperable tricuspid surgical prosthesis dysfunction? Thirty-day mortality after greatly effective transcatheter treatment is 2 times less than the estimated surgical risk.

Transcatheter treatment of the tricuspid valve: current status and perspectives

Transcatheter tricuspid valve interventions (TTVI) are emerging as alternatives to surgery in high-risk patients with isolated or concomitant tricuspid regurgitation. The development of new minimally invasive solutions potentially more adapted to this largely undertreated population of patients, has fuelled the interest for the tricuspid valve. Growing evidence and new concepts have contributed to revise obsolete and misleading perceptions around the right side of the heart. New definitions, classifications, and a better understanding of the disease pathophysiology and phenotypes, as well as their associated patient journeys have profoundly and durably changed the landscape of tricuspid disease. A number of registries and a recent randomized controlled pivotal trial provide preliminary guidance for decision-making. TTVI seem to be very safe and effective in selected patients, although clinical benefits beyond improved quality of life remain to be demonstrated. Even if more efforts are needed, increased disease awareness is gaining momentum in the community and supports the establishment of dedicated expert valve centres. This review is summarizing the achievements in the field and provides perspectives for a less invasive management of a no-more-forgotten disease.

Transjugular tricuspid valve-in-ring replacement using the novel system under three-dimensional printing guidance

Recurrent tricuspid regurgitation after failed ring annuloplasty is associated with high mortality rates and unfavourable clinical outcomes. Transcatheter tricuspid valve-in-ring (TVIR) replacement offers an alternative to high-risk surgical reoperation, but challenges remain. We present a case of a 67-year-old male who underwent tricuspid annuloplasty 3 years ago and developed severe recurrent tricuspid regurgitation (regurgitation volume = 36 mL) 6 months ago. To avoid a high-risk thoracotomy, we finally performed TVIR replacement using the novel device, LuX-Valve Plus system, via the transjugular approach. Cardiovascular three-dimensional printing technology was utilized to investigate the distinct advantages offered by the new device in this specific intervention, as well as to simulate the procedure. Successful TVIR replacement resulted in significant symptomatic improvement. TVIR replacement with the LuX-Valve Plus system is feasible for failed annuloplasty ring cases. Patient-specific three-dimensional printed models enable personalized procedural planning, enhancing safety and precision.

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.

Cardiac Reverse Remodeling and Changes in Heart Failure Indices After Transcatheter Tricuspid Valve Replacement in Adults With Congenital Heart Disease

BACKGROUND

There are limited data about changes in cardiac function (cardiac reverse remodeling) and heart failure indices after transcatheter tricuspid valve-in-valve replacement (TT-VIVR). The purpose of this study was to evaluate cardiac reverse remodeling and temporal changes in heart failure indices after TT-VIVR in adults with congenital heart disease.

METHODS

Retrospective cohort study of adults with congenital heart disease that underwent TT-VIVR and had >6 months of follow-up (January 1, 2011, to April 30, 2023). Echocardiographic indices of cardiac remodeling and heart failure indices (New York Heart Association class, NT-proBNP (N-terminal pro-brain natriuretic peptide), glomerular filtration rate, and model for end-stage liver disease excluding international normalized ratio score) were assessed preintervention and at 1-, 3-, and 5-year postintervention.

RESULTS

Of 39 patients (age 39 [32-46] years), 14 (36%) and 25 (64%) received Melody valve and Sapien valve prosthesis, respectively. At 1-year post-TT-VIVR, there was a temporal improvement in right atrial reservoir strain (17±8% versus 22±8%, P<0.001), right atrial volume (81 [59-108] versus 63 [48-82] mL/m2, P<0.001), right atrial pressure (12±4% versus 6±4%, P<0.001), and right ventricular global longitudinal strain (-15±7% versus -20±7%, P<0.001). Similarly, there was a temporal improvement in NT-proBNP, glomerular filtration rate, model for end-stage liver disease excluding international normalized ratio score, and New York Heart Association class. The temporal improvements in heart failure indices and valve function were maintained at 3- and 5-year post-TT-VIVR.

CONCLUSIONS

Considering the significant mortality risk associated with reoperations for tricuspid valve replacement, these data suggest favorable outcomes after TT-VIVR, and support TT-VIVR as a viable alternative to surgical tricuspid valve replacement, especially in high-risk patients.

Guidelines for the Evaluation of Prosthetic Valve Function With Cardiovascular Imaging: A Report From the American Society of Echocardiography Developed in Collaboration With the Society for Cardiovascular Magnetic Resonance and the Society of Cardiovascular Computed Tomography

In patients with significant cardiac valvular disease, intervention with either valve repair or valve replacement may be inevitable. Although valve repair is frequently performed, especially for mitral and tricuspid regurgitation, valve replacement remains common, particularly in adults. Diagnostic methods are often needed to assess the function of the prosthesis. Echocardiography is the first-line method for noninvasive evaluation of prosthetic valve function. The transthoracic approach is complemented with two-dimensional and three-dimensional transesophageal echocardiography for further refinement of valve morphology and function when needed. More recently, advances in computed tomography and cardiac magnetic resonance have enhanced their roles in evaluating valvular heart disease. This document offers a review of the echocardiographic techniques used and provides recommendations and general guidelines for evaluation of prosthetic valve function on the basis of the scientific literature and consensus of a panel of experts. This guideline discusses the role of advanced imaging with transesophageal echocardiography, cardiac computed tomography, and cardiac magnetic resonance in evaluating prosthetic valve structure, function, and regurgitation. It replaces the 2009 American Society of Echocardiography guideline on prosthetic valves and complements the 2019 guideline on the evaluation of valvular regurgitation after percutaneous valve repair or replacement.

Tricuspid Regurgitation: From Imaging to Clinical Trials to Resolving the Unmet Need for Treatment

Tricuspid regurgitation (TR) is a highly prevalent and heterogeneous valvular disease, independently associated with excess mortality and high morbidity in all clinical contexts. TR is profoundly undertreated by surgery and is often discovered late in patients presenting with right-sided heart failure. To address the issue of undertreatment and poor clinical outcomes without intervention, numerous structural tricuspid interventional devices have been and are in development, a challenging process due to the unique anatomic and physiological characteristics of the tricuspid valve, and warranting well-designed clinical trials. The path from routine practice TR detection to appropriate TR evaluation, to conduction of clinical trials, to enriched therapeutic possibilities for improving TR access to treatment and outcomes in routine practice is complex. Therefore, this paper summarizes the key points and methods crucial to TR detection, quantitation, categorization, risk-scoring, intervention-monitoring, and outcomes evaluation, particularly of right-sided function, and to clinical trial development and conduct, for both interventional and surgical groups.

Update on Transcatheter Treatment of Mitral and Tricuspid Valve Regurgitation

PURPOSE OF REVIEW

Mitral and tricuspid regurgitation represents a clinical challenge. They are associated with a poor prognosis, and many patients are not eligible for conventional surgery. Transcatheter therapies have been the focus of numerous studies and devices over the past decade. Here, we provide a summary of current options for transcatheter treatment of these 2 entities.

RECENT FINDINGS

Recent studies have demonstrated the benefits of edge-to-edge repair for increasing numbers of patients. Encouraging early results with transcatheter valve replacement are also becoming available. To date, transcatheter edge-to-edge repair is currently the first-line transcatheter treatment for both mitral and tricuspid regurgitation for many patients who are not candidates for surgery. A number of transcatheter replacement devices are under development and clinical investigation but, for the most part, their current use is limited to compassionate cases or clinical trials.

Post-procedural structural heart CT imaging: TAVR, TMVR, and other interventions

Transcatheter valve replacement has experienced substantial growth in the past decade and this technique can now be used for any of the four heart valves. Transcatheter aortic valve replacement (TAVR) has overtaken surgical aortic valve replacement. Transcatheter mitral valve replacement (TMVR) is often performed in pre-existing valves or after prior valve repair, although numerous devices are undergoing trials for replacement of native valves. Transcatheter tricuspid valve replacement (TTVR) is similarly under active development. Lastly, transcatheter pulmonic valve replacement (TPVR) is most often used for revision treatment of congenital heart disease. Given the growth of these techniques, radiologists are increasingly called upon to interpret post-procedural imaging for these patients, particularly with CT. These cases will often arise unexpectedly and require detailed knowledge of potential post-procedural appearances. We review both normal and abnormal post-procedural findings on CT. Certain complications-device migration or embolization, paravalvular leak, or leaflet thrombosis-can occur after replacement of any valve. Other complications are specific to each type of valve, including coronary artery occlusion after TAVR, coronary artery compression after TPVR, or left ventricular outflow tract obstruction after TMVR. Finally, we review access-related complications, which are of particular concern due to the requirement of large-bore catheters for these procedures.

Transcatheter Melody Valve Placement in a Native Right Atrioventricular Valve in a Pediatric Patient

Transcatheter tricuspid valve placement in congenital heart disease is becoming increasingly used when a previously placed surgical ringed valve becomes dysfunctional. Surgically repaired and/or native tricuspid inflows are generally not amenable to transcatheter valve placement without a prior ring being placed. We present the second pediatric case to our knowledge of transcatheter tricuspid valve placement in a surgically repaired tricuspid valve in the absence of a ring.

Predictive value of the TRI-SCORE for in-hospital mortality after redo isolated tricuspid valve surgery

OBJECTIVES

The TRI-SCORE reliably predicts in-hospital mortality after isolated tricuspid valve surgery (ITVS) on native valve but has not been tested in the setting of redo interventions. We aimed to evaluate the predictive value of the TRI-SCORE for in-hospital mortality in patients with redo ITVS and to compare its accuracy with conventional surgical risk scores.

METHODS

Using a mandatory administrative database, we identified all consecutive adult patients who underwent a redo ITVS at 12 French tertiary centres between 2007 and 2017. Baseline characteristics and outcomes were collected from chart review and surgical scores were calculated.

RESULTS

We identified 70 patients who underwent a redo ITVS (54±15 years, 63% female). Prior intervention was a tricuspid valve repair in 51% and a replacement in 49%, and was combined with another surgery in 41%. A tricuspid valve replacement was performed in all patients for the redo surgery. Overall, in-hospital mortality and major postoperative complication rates were 10% and 34%, respectively. The TRI-SCORE was the only surgical risk score associated with in-hospital mortality (p=0.005). The area under the receiver operating characteristic curve for the TRI-SCORE was 0.83, much higher than for the logistic EuroSCORE (0.58) or EuroSCORE II (0.61). The TRI-SCORE was also associated with major postoperative complication rates and survival free of readmissions for heart failure.

CONCLUSION

Redo ITVS was rarely performed and was associated with an overall high in-hospital mortality and morbidity, but hiding important individual disparities. The TRI-SCORE accurately predicted in-hospital mortality after redo ITVS and may guide clinical decision-making process (www.tri-score.com).

Transcatheter tricuspid valve-in-valve implantation for degenerated surgical bioprosthesis

BACKGROUND

Isolated redo surgery for degenerated tricuspid bioprosthesis is of very high risk. We aimed to evaluate the safety and efficacy of transcatheter valve-in-valve (TVIV) implantation using a novel balloon expandable Renato valve.

METHODS

A prospective multicenter study was conducted to enroll patients with degenerated tricuspid bioprostheses. A total of 12 patients underwent TVIV implantation using the Renato valve system via transfemoral, transjugular, or transatrial approaches at three institutions from May 2021 to October 2021. All-cause mortality and hemodynamic performance were evaluated up to 6 months after procedure.

RESULTS

The median age was 68.2 years, and 75.0% were female. Six patients had a history of rheumatic left-sided valve surgery and late tricuspid valve replacement. The median preoperative Society of Thoracic Surgeons score was 9.9%. The procedures were successful in all cases. Tricuspid regurgitation and paravalvular leak were none or mild in all patients. The median transvalvular gradient decreased from 7.8 mmHg preoperatively to 4.5 mmHg at 6 months after TVIV, respectively. No death occurred and all patients recovered to New York Heart Association functional class I or II during a 6-month follow-up.

CONCLUSIONS

TVIV implantation with the Renato valve was a safe and effective treatment for degenerated bioprostheses in high-risk patients.

Original technique for tricuspid valve replacement by mitral homograft: Step-by-step approach and initial results

INTRODUCTION

Severe tricuspid regurgitation is associated with the progression of heart failure symptoms and poor survival. Surgical treatment of infective and prosthetic tricuspid valve endocarditis using homografts gives promising early and midterm results. Tricuspid valve replacement with a mitral homograft is a reasonable procedure with a challenging technique.

MATERIAL AND METHODS

A total of 15 patients underwent tricuspid valve replacement by mitral homograft in two departments from October 2020 to May 2022. The mean age was 36 [31-40.5]. In this article, we describe our original step-by-step technique and initial experience of successful use of native or cryopreserved mitral homografts for surgical treatment of tricuspid valve disease.

RESULTS

There were no in-hospital and 30-day mortality, no postoperative bleeding, myocardium infarction, stroke, or sternal wound infection. Only one patient required permanent pacemaker implantation after redo surgery before discharge. The predischarge echocardiogram showed no residual tricuspid regurgitation (TR) in 14 cases (93.3%) and mild TR in 1 (6.7%) patient. All patients were discharged from the hospital without symptoms of endocarditis, with negative blood culture samples.

CONCLUSION

Satisfactory initial clinical and hemodynamic results were achieved utilizing our technique. Mid- and long-term results are required to understand the place of homografts in tricuspid valve surgery.

Early Valve Thrombosis Management After Successful Transcatheter Tricuspid Valve-in-Valve Implantation

Transcatheter tricuspid valve-in-valve implantation is a critical option in high risk bioprosthetic tricuspid valve dysfunction. In this case report, balloon-expandable transcatheter heart valve was implanted successfully into the tricuspid valve and early thrombosis was managed successfully. (Level of Difficulty: Intermediate.).

Transcatheter Tricuspid Valve-in-Valve Replacement Using a J-Valve System for a Failed Tricuspid Bioprosthesis

Background

Redo operation for failed tricuspid bioprosthetic valves is associated with high morbidity and mortality. Transcatheter tricuspid valve-in-valve implantation has become an acceptable option for high-risk patients with a failed tricuspid bioprosthesis. We present a case of successful tricuspid valve-in-valve implantation using a J-valve in a failed tricuspid bioprosthesis position. Case Summary. A 48-year-old male, who had a failed tricuspid bioprosthesis, presented with right-side heart failure, right-to-left shunting at the atrial level, severe dyspnea, cyanosis, peripheral edema, hepatauxe, and ascites. After the interdisciplinary assessment, we successfully performed transcatheter tricuspid valve-in-valve implantation with the J-valve system. At 34-month postoperative follow-up, the patient had no symptoms of heart failure and the echocardiogram showed good valve position and well hemodynamic status.

Conclusions

This case demonstrated that the J-valve system may be a new option for high-risk patients with a failed tricuspid bioprosthetic valve.

Tricuspid valve replacement: The old and the new

Tricuspid regurgitation is a frequent and serious condition but tricuspid valve (TV) surgery, that may be a valve replacement when a repair is not feasible, is rarely performed. Recent development of transcatheter TV interventions offers new options for those high-surgical risk patients, especially TV replacement for patients who are not eligible for transcatheter TV repair. In this review, we describe indications and outcome after surgical TV replacement, and devices available or in development for transcatheter TV replacement.

Current Status of Transcatheter Tricuspid Valve Therapies

Tricuspid regurgitation is a complex disease that carries a poor prognosis, and surgical repair is associated with high mortality. In light of the success of other transcatheter-based valve interventions, transcatheter tricuspid therapy has recently seen exponential use both clinically and in innovation. Given the rapid development of many tricuspid systems and multiple on-going clinical trials, the aim of this review is to highlight the current state of transcatheter tricuspid therapeutics and to provide an up-to-date view of their clinical use, outcomes and future directions.

Interventions for Congenital Atrioventricular Valve Dysfunction: JACC Focus Seminar

Innovation and creativity have led to tremendous advancements in the care and management of patients with congenital heart disease (CHD) that have resulted in considerably increased survival. Catheter-based interventions have contributed significantly to these advancements. However, catheter-based interventions for congenital lesions of the atrioventricular (AV) valves have been limited in scope and effectiveness mainly because of patient size and anatomical challenges. Thus, surgical repair and replacement for congenital AV valve lesions have remained the preferred therapy. However, the ongoing transcatheter heart valve revolution has led to techniques and technologies that are changing the landscape, particularly for adult CHD patients. Many devices for AV valve repair and replacement are being studied in adult patients without CHD, and translation of select practices to CHD patients has begun, with many more to come. Transcatheter AV valve interventions represent exciting opportunities for the growing numbers of adult CHD patients.

Tricuspid Structural Valve Deterioration Treated with a Transcatheter Valve-in-Valve Implantation: A Single-Center Prospective Registry

The valve-in-valve (ViV) technique is an emerging alternative for the treatment of bioprosthetic structural valve deterioration (SVD) in the tricuspid position. We report on the outcomes of patients treated by a transcatheter tricuspid valve-in-valve (TT-ViV) implantation for symptomatic SVD in the tricuspid position during the years 2010-2019 at our center. Three main outcomes were examined during the follow-up period: TT-ViV hemodynamic data per echocardiography, mortality and NYHA functional class. Our cohort consisted of 12 patients with a mean age 65.4 ± 11.9 years, 83.3% male. The mean time from initial valve intervention to TT-ViV was 17.4 ± 8.7 years. The indications for TT-ViV were varied (41.7% for predominant regurgitation, 33.3% for predominant stenosis and 25.0% with a mixed pathology). All patients were treated with a balloon-expandable device. The mean follow-up was 3.4 ± 1.3 years. Tricuspid regurgitation was ≥ moderate in 57.2% of patients prior to the procedure and this decreased to 0% following the procedure. The mean transtricuspid valve gradients mildly decreased from the mean pre-procedural values of 9.0 mmHg to 7.0 mmHg at one month following the procedure (p = 0.36). Mortality at one year was 8.0% (95% CI 0-23). At the baseline, 4 patients (33.3%) were in NYHA functional class III/IV; this was reduced to 2 patients (18.2%) at the one year follow-up and both were in NYHA III. The TT-ViV procedure offered a safe, feasible and less invasive treatment option for patients with SVD in our detailed cohort.

A case of early thrombosis following a percutaneous tricuspid valve in valve implantation managed by thrombolysis

Bioprosthetic valve thrombosis (BPVT) is a growing recognized entity, especially with the increasing use of the valve in vale procedures and the advent of new detection technologies (e.g., 4D CT and 4D echocardiography). The incidence of BPVT is higher in transcatheter valves than surgically implanted bioprosthetic valves. However, the best thromboprophylaxis regimen and optimal management strategy in the acute context remain unknown. This paper presents a case of early thrombosis following the percutaneous tricuspid valve in vale procedure that was successfully managed with thrombolysis.

Simultaneous transcatheter tricuspid and mitral valve-in-valve replacement for the treatment of degenerated bioprosthetic valves

Transcatheter valve-in-valve replacement has become a viable option for patients with degenerated bioprosthetic valves at high risk for redo surgery. We report a case of a patient who had degenerated mitral and tricuspid bioprosthesis causing severe tricuspid and mitral regurgitation. We performed simultaneous mitral and tricuspid valve-in-valve replacement via a transfemoral approach. Although the data on performing both valve-in-valve procedures are limited, this case demonstrated that these procedures can be safely done as a single procedure.

Editorial commentary: Cutting the Gordian knot of right-sided prosthetic valve thrombosis

With limited data available for the tricuspid valve, there are no stringent recommendations in the current guidelines (ESC 2021). Valve replacement for the right-sided heart is inherently problematic and bears the potential for complications - including prosthetic valve thrombosis (PVT). The purpose of this editorial is to review the key features of this clinical scenario and to outline the essential aspects for optimized patient management and improved outcome. Depending on the clinical presentation of PVT, either immediate surgery, thrombolysis, or anticoagulation may be considered - with the sole intensification of anticoagulation likely being the most inferior. Given the high risk of re-thrombosis, a dedicated follow-up program is essential to identify complications early and offer adequate treatment.

Melody valve insertion for relief of "Tricuspid" stenosis in an unbalanced atrioventricular septal defect

A Melody valve was successfully placed across a very stenotic right-sided component of a common atrioventricular valve because of ongoing troublesome arrhythmias in a young woman with an unbalanced atrioventricular septal defect, a very dilated right atrium and a hypoplastic right ventricle. Four years later, she remains well.

Melody valve-in-valve implantation in the tricuspid position through a Fontan conduit fenestration

Patients with single right ventricle and tricuspid regurgitation have increased morbidity and mortality rates. The outcomes of surgical tricuspid valve repair and replacement are dismal. Although some centers prefer valve replacement with a bioprosthetic valve in the tricuspid position for the pediatric population, these valves have limited longevity and will eventually need to be replaced. Unfortunately, single ventricle patients are fragile and unlikely to tolerate a second replacement. Percutaneous valve-in-valve (ViV) implantation is an acceptable alternative with low morbidity and mortality. Studies have also shown acceptable short- and mid-term outcomes. We report a case of Melody ViV placement in the tricuspid position in a patient with hypoplastic left heart syndrome through the fenestration of a Fontan conduit.

The Transcatheter Tricuspid Valve-in-Valve Technique in Degenerated Bioprostheses Without Fluoroscopic Radiopaque Landmarks

Nonetheless, in principle, bioprosthetic heart valves are often preferred to mechanical valves in that not only do they obviate the need for high-level systemic anticoagulation and the attendant bleeding risks, but also higher rates of prosthetic valve thrombosis have been reported observed in the tricuspid position. The transcatheter tricuspid valve-in-valve (TVIV) procedure has expanded the horizons of cardiac surgery by allowing the implantation of stent-valves within degenerated bioprostheses in older adults and even young patients as the reported rate of the mortality of redo surgery in antecedent studies is at least 37%. Fluoroscopic guidance can assist the operator in implanting a bioprosthetic valve by radiopaque findings in the ideal position and depth; nonetheless, the complete radiolucency of some bioprosthetic valves represents a significant hurdle. In this state-of-the-art manuscript, we decided to deeply explain the appropriate heart-team approach in this scenario.

Challenges and future perspectives of transcatheter tricuspid valve interventions: adopt old strategies or adapt to new opportunities?

Tricuspid regurgitation (TR) is a highly prevalent valvular heart disease and is associated with an increased risk of cardiovascular events and death at long-term follow-up. Functional TR accounts for over 90% of TR and is mainly due to annular or right ventricular dilatation. Most often, TR is observed in patients with left-sided valvular heart disease (with or without previous surgical correction) and pulmonary hypertension. Isolated TR is less frequent, though burdened by high surgical mortality. This, together with an incomplete understanding of the disease, has brought to a significant undertreatment in spite of the growing evidence of the impact of severe TR on mortality. Moreover, uncertainties about the appropriate timing for intervention and the predictors of procedural success have contributed to limit TR treatment. Transcatheter tricuspid valve replacement or repair interventions represent novel and less invasive alternatives to surgery and have shown early promising results. The purpose of this review is to provide a complete and updated overview of TR pathology with a special focus on current percutaneous treatment options, future challenges and directions.

Transcatheter Tricuspid Valve Replacement for Surgical Failures

Tricuspid valve surgery has high mortality for first-time operations and repeat surgery is fraught with even higher rates. When failed tricuspid surgical prostheses and repairs are present, physicians look toward transcatheter tricuspid valve replacement (TTVR) as a tangible solution. Using balloon-expandable bioprosthetic valves in an off-label fashion, tricuspid valve-in-valve (TViV) procedures can be performed reliably; however, valve-in-ring cases are more nuanced and have higher risks of paravalvular leak and valve malpositioning. TTVR specific issues include THV anchoring, management of preexisting pacing leads, postprocedure thromboembolic prophylaxis, and possible tricuspid reintervention.

Orthotopic Transcatheter Tricuspid Valve Replacement

Severe tricuspid regurgitation renders patients frail, and surgical treatment is associated with high mortality. Because most of the tricuspid regurgitation patients are functional and have significant annular dilation, large coaptation gaps are seen. This anatomy is best addressed with transcatheter tricuspid valve replacement (TTVR), and promising therapies are under clinical investigation. Most TTVR devices are in early clinical development with one transcatheter heart valve in pivotal trial; TTVR is expected to significantly affect tricuspid regurgitation and survival.

Transcatheter valve implantation for degenerated tricuspid bioprosthesis and failed tricuspid ring

Background

Transcatheter tricuspid valve-in-valve (TViV) and valve in-ring (TViR) implantation have become a viable therapy for a failed tricuspid bioprosthesis. Here we report short (thirty days) and long (one-year) term clinical outcomes of ten patients who underwent TViV at our institution.

Methods

The electronic databases of New York Presbyterian Columbia Medical Center were retrospectively reviewed for cases of transcatheter tricuspid valve replacement (TViV or TViR). Between 2012 and 2019, data from ten patients who underwent TViV were collected. The primary safety outcome was procedure-related adverse events, including clinically evident cardiac perforation, new pericardial effusion and sustained ventricular arrhythmia. The primary efficacy endpoint was defined as successful valve deployment with total (paravalvular or intravalvular) tricuspid regurgitation (TR) estimated as mild or less. Results are descriptive in nature.

Results

A total of ten patients who underwent TViV were included in the study. Of them, 40% presented with isolated tricuspid bioprosthetic stenosis (TS), 20% with isolated TR and 40% with mixed TS and TR. All patients were treated with the SAPIEN valve (first generation, XT, or Sapien 3). The TViV procedure was successful in all patients, and no immediate post-replacement paravalvular leak (PVL) or intra-procedural complications were reported. The primary safety and efficacy endpoints were met in all patients. At thirty-days, all patients were alive and reported significant improvements in symptoms and functional status.

Conclusions

Transcatheter tricuspid valve implantation is a safe and effective therapy for degenerative tricuspid bioprosthesis.

Transcatheter tricuspid valve-in-valve implantation for degenerative surgical bio-prosthesis using SAPIEN 3: A case series

We evaluated early outcomes of transcatheter valve-in-valve (ViV) implantation in patients with degenerated bio-prosthesis in tricuspid position. Total of 5 patients were included in our case series. Baseline native tricuspid valve etiology were highly varied ranging from chest wall trauma, Ebstein anomaly, rheumatic heart disease, infective endocarditis and complex congenital heart disease. These differences also made patient comorbidities highly varied. Procedure details were also varied due to different clinical and technical challenges. All cases underwent successful Tricuspid VIV implantation with satisfactory hemodynamics results. All patients experienced improved clinical symptoms at follow up.

Reappraisal of mechanical tricuspid valve replacement in the current era: a single center retrospective study

Background

This study aimed to investigate the early and late outcomes of mechanical tricuspid valve replacement (mTVR).

Methods

We evaluated 113 patients (82 women; median age, 53 years) who underwent mTVR between 1995 and 2017. Based on a history of cardiac surgery, patients were divided into primary (n=42) and reoperative mTVR (n=71) groups. The median follow-up duration was 12.7 years in primary and 9.3 years in reoperative mTVR, respectively (P=0.045).

Results

Patients in the reoperative group were older (54 vs. 46 years; P=0.007) and showed higher central venous pressure (16±6 vs. 13±6 mmHg; P=0.002) than the primary group. Early mortality occurred in 2 patients in the reoperative group (2 vs. 0; P=0.529). There was no significant difference in overall survival between the primary and reoperation groups (15-year survival rate: 86% vs. 78%; P=0.215). The independent risk factors of overall survival were age [P<0.001; hazard ratio (HR), 1.11; 95% confidential interval (CI), 1.05–1.18], left ventricular ejection fraction of less than 40% (P=0.001; HR, 5.1; 95% CI, 2.21–28.2), and central venous pressure over 20 mmHg (P=0.016; HR, 3.7; 95% CI, 1.28–10.7). Overall survival did not differ between the age groups (<60 vs. 60–70 years) in the reoperative group (P=0.772). Tricuspid valve thrombosis occurred in 8 patients (7 primary, 1 reoperative; P=0.004).

Conclusions

The incidence of tricuspid valve thrombosis was significantly higher in the primary mTVR group compared with the reoperative mTVR group. The patients who underwent mTVR at a relatively young age showed good early and late outcomes in both groups.

Transcatheter valve-in-valve-in-valve replacement in tricuspid position in a patient with pre-existing permanent dual-chamber pacemaker

Graphic abstract

Double transcatheter balloon-expandable valve implantation for severe valve dysfunction in high-risk patients: initial experience

OBJECTIVES

Concomitant valvular heart valve disease is a frequent finding, with higher morbidity and mortality among patients undergoing redo surgical procedures. Our goal was to report our initial experience with combined transcatheter Inovare bioprosthesis implants for severe valve dysfunction.

METHODS

Among 300 transcatheter procedures, a total of 6 patients had concurrent simultaneous transcatheter bioprosthesis implants for severe mitral bioprosthesis failure (valve-in-valve), with a second valve procedure that included native aortic (n = 2) or degenerated bioprostheses in the aortic position (n = 4). During the procedures, all patients were treated with a balloon-expandable Inovare transcatheter valve, using the transapical approach.

RESULTS

Patients were highly symptomatic [New York Heart Association (NYHA) functional class IV: 100%], with a mean age of 62 ± 5 years, yielding a mean European System for Cardiac Operative Risk II (EuroSCORE II) of 24.0 ± 10.1%. There was a mean of 1.6 ± 0.4 prior valve operations/patient, with a median time from prior mitral bioprosthesis surgery of 13.0 (9.2-20.0) years. Device success was 100% according to the Mitral Valve Academic Research Consortium and the Valve Academic Research Consortium-2 criteria. During the hospital stay, only 1 patient required dialysis, and the median intensive care unit and hospital lengths of stay were 5.0 (3.2-6.7) days and 16.0 (12.2-21.2) days, respectively. No deaths occurred at 30 days; at a median follow-up of 287 (194-437) days, 1 patient died of a non-cardiac cause and the rest of patients were in NYHA functional class I or II, with normofunctioning bioprostheses.

CONCLUSIONS

Transcatheter double valve interventions using the Inovare bioprosthesis in this initial series were shown to be a reasonable alternative to redo surgical operations. The short- and mid-term clinical and echocardiographic outcomes demonstrate promising results, although future studies with a larger number of patients and longer follow-up are warranted.

Transcatheter tricuspid valve replacement in dehisced flexible ring

Transcatheter tricuspid valve-in-surgical annuloplasty ring is an appealing concept in light of the high mortality associated with reoperation on the tricuspid valve. The clinical necessity of this procedure is derived from a considerable failure rate of tricuspid repairs over time. The presented case demonstrates that transcatheter valve-in-ring is a feasible option for patients with flexible tricuspid ring even in the context of significant ring dehiscence. Meticulous procedural planning, preemptively addressing a potential paravalvular leak, and clear understanding of the intricate three-dimensional anatomy are imperative for procedural success.

Transcatheter treatment by valve-in-valve and valve-in-ring implantation for prosthetic tricuspid valve dysfunction

Valve degeneration after surgical tricuspid valve replacement or repair is frequent and may require repeat replacement/repair. For high-risk patients, transcatheter valve-in-valve and valve-in-ring procedures have emerged as valuable treatment alternatives. Preprocedural transthoracic echocardiography is the method of choice to detect malfunction of the prosthesis including degenerative stenosis and/or regurgitation requiring reintervention. Subsequently, computed tomography is helpful for detailed anatomical analysis and periprocedural planning. Device selection and sizing depend on the size and structural details of the implanted ring or prosthesis. The procedure is mainly guided by fluoroscopy; however, transesophageal echocardiography provides complementary guidance during device implantation. Preferred access route is the right femoral vein but in cases of more horizontal implants a jugular approach might be feasible. Suitable transcatheter valves are the Edwards Sapien 3 and the Medtronic Melody valves. Differences in surgical prostheses or annuloplasty implants are important for device selection, height consideration and additional ballooning prior to or after implantation. Transesophageal echocardiography postimplantation is convenient for the assessment of transvalvular gradients or paravalvular leaks.

Transcatheter Tricuspid Valve-in-Valve Implantation With a Novel Balloon Expandable Myval THV

The transcatheter tricuspid valve-in-valve implantation has not yet been clarified, and several case series have documented results in patients with tricuspid bioprosthetic valve degeneration who underwent transcatheter implantation of Edwards SAPIEN XT and SAPIEN 3 (Edwards Lifesciences, Irvine, CA) and Medtronic (Minneapolis, MN) valves. Here, we present the case of a patient with severe bioprosthetic tricuspid valve stenosis who was successfully treated with the transfemoral route through the 29-mm novel balloon expandable Myval transcatheter heart valve (Meril Life Sciences Pvt Ltd, Vapi, Gujarat, India) system.

Scalloped Freehand Pulmonary Homograft for Prosthetic Tricuspid Valve Replacement

Tricuspid valve replacement is commonly performed using biologic or mechanical prostheses. Partial or complete valve replacement using mitral homograft tissue has also been described. Anecdotal reports exist of valve replacement using a pulmonary homograft within a cylinder. This report describes a technique for native or prosthetic valve replacement using a freehand scalloped pulmonary homograft. Late follow-up confirmed the efficacy of this surgical strategy.

A case report of isolated severe valve stenosis in a previous tricuspid valve repair: an integrated multimodality imaging and invasive haemodynamic evaluation

Background

Tricuspid valve (TV) stenosis is a very rare condition and the aetiology is primarily due to rheumatic disease, carcinoid disease, congenital heart disease, endocarditis, and following degeneration of biological valve prosthesis.

Case summary

We present a 45-year-old man with a rare case of symptomatic TV stenosis (TS) in a previously isolated TV repair. A meticulous multimodality diagnostic approach is presented in order to determine the severity of the TS and to evaluate the right ventricular function.

Discussion

This case report presents an integrated multimodality imaging and haemodynamic approach to evaluate and document the suspicion of development of a symptomatic significant stenosis in a previous TV repair. The initial TV repair was done without ring annuloplasty, because only the anterior leaflet was affected and bicuspidalization of the valve made it patent. In addition, minimizing the amount of implanted material was intended to minimize the risk of reinfection. The final treatment was performed as a TV replacement with insertion of a bioprosthesis.