Question of the week
ESCardioEd challenge by Dr Francesco Petracca and team, Cardiocentro Ticino Institute, Lugano, Switzerland.
A 44-year-old woman with history of drug addiction and cirrhosis related to chronic hepatitis C infection, presented to the out-patient clinic with severe right-sided heart failure. She underwent partial tricuspid valve resection and De Vega annuloplasty in 2001 for infective endocarditis and in 2009 a tricuspid valve replacement with a Carpentier-Edwards Perimount Magna 31 mm valve, for symptomatic severe tricuspid regurgitation recurrence.
Transthoracic echocardiography on admission showed degeneration of the bioprosthetic valve.
The heart team decided to proceed with a trans-jugular implantation of a new valve in view of the patient’s overall frailty and significant comorbid conditions.
The preoperative computed tomography showed total occlusion of the internal jugular vein up to the subclavian vein confluence (figure 2 below), making this vascular access route unsuitable.
What vascular access would you choose?
Occlusion of the internal jugular vein made it necessary to perform the procedure through a trans-femoral (TF) venous route.
A 29-mm Edwards Sapien 3 transcatheter heart valve (Edwards Lifesciences) was inserted over the wire in the inferior vena cava. Under fluoroscopic and transesophageal echocardiographic guidance, the valve was then advanced into the degenerated tricuspid biological prosthesis (Figure 3 below) and positioned in the usual manner for Sapien 3 valve deployment, with use of the prior stent’s frame as a reference. The valve was deployed with excellent results (Figure 4). Post-deployment echocardiogram confirmed a well-positioned valve, with optimal placement, and a trivial pari-valvular leak.
The patient tolerated the procedure well with no peri-procedural complications, reporting an immediate improvement in her symptoms.
At 12 months follow-up the patient is stable, asymptomatic, with no other hospital admission for acute decompensated right heart failure.
TF transcatheter tricuspid valve-in-valve replacement is a valid therapeutic option in patients with prohibitive surgical risk. This access is safe and feasible and allows good prosthesis positioning. Multimodality imaging and discussion in a heart team helps to make the optimal treatment decisions.