Page 30 - Journal of Structural Heart Disease Volume 3, Issue 2

Case Report
56
patients develop moderate or severe regurgitation within 5 years [1, 2]. In patients with congenital forms of TR, surgical replacement may be necessary at a young age; longer-lasting mechanical valves would require placing young patients on anticoag- ulants, and yet bioprosthetic valves commonly re- quire replacement within 10–15 years [3, 4]. Use of biological valves early in life most certainly predicts multiple reoperations as they begin to fail, and re- peat surgery is associated with increased morbidity and mortality [5].
Percutaneous TV replacement may be a viable al- ternative to surgical reoperation. This procedure has been well documented in the aortic and pulmonary valve positions, and there is a growing body of evi- dence for the use of both the Melody (Medtronic Inc.) and Sapien (Edwards Lifesciences) valves in failing TV rings and bioprostheses [6]. Although the proce- dural success rate is high with immediate hemody- namic bene ts, there is paucity of long-term data. In terms of recurrent TR post annuloplasty, successful utilization of transcatheter valves is limited to iso- lated case reports and small case series [7, 8, 9]. The present report details two cases of transcatheter TV replacement—one within a failing bioprosthesis and the other in a regurgitant native valve with an in- complete annuloplasty ring—and seeks to highlight the di erences in technique, device selection, and procedural outcomes.
Case 1: Failing Bioprosthesis
A 23-year-old male born with Ebstein’s anomaly and ostium secundum atrial septal defect underwent surgical TV repair at 3 years of age. Complications in- cluded prolonged intensive care unit stay and a ster- nal wound infection. At 14 years of age, he underwent surgical TV replacement with a 33-mm Hancock bio- prosthesis due to progressive TR and recurrent atrial arrhythmias. Complications included ventricular bril- lation and bleeding requiring resuscitation and explo- ration, again resulting in a prolonged hospital course. He did well thereafter and was not cyanotic, therefore the atrial septal defect was percutaneously closed. A decade later, he developed progressive symptoms and signs of RV failure and volume overload and was noted to have severe stenosis and moderate regurgitation of the bioprosthetic TV. Due to multiple prior sternoto- mies and surgical complications, the patient and sur- geon preference was to avoid further surgery. He was therefore referred for transcatheter valve replacement.
The patient underwent uncomplicated percuta- neous tricuspid valve-in-valve (TVIV) replacement with a 22-mm Melody valve under general anesthe- sia with transesophageal echocardiography ( TEE) guidance. The right femoral vein was utilized for right heart catheterization and TV intervention. Pre-inter- ventional mean in ow gradient was 6 mmHg with a heart rate of 55 beats per minute (bpm; Figure 1A).
AB
Figure 1. Panel A. Pre-deployment mean RV-pulmonary artery gradient measurement of 6 mmHg, Fick cardiac output of 4.45 L/min, and estimated TV area by the Gorlin formula of 0.97 cm2. Panel B. Post-deployment mean RV-pulmonary artery gradient measurement of 2 mmHg.
Journal of Structural Heart Disease, April 2017 Volume 3, Issue 2:55-61