Successful valve-in-valve transcatheter intervention to treat severe stenosis of a 38-year-old tricuspid bioprosthesis.

A 60-year-old man presented with breathlessness. Nearly four decades previously, he had required three operations for Staphylococcus aureus infective endocarditis of the tricuspid valve and had received a bioprosthetic valve. He had critical tricuspid bioprosthesis stenosis which was treated successfully by valve-in-valve transcatheter tricuspid valve replacement using a balloon-expandable transcatheter heart valve. One year after intervention, the patient is well with no tricuspid valve stenosis or regurgitation.

Balloon valvuloplasty for annular- and leaflet-level tricuspid stenosis: Report of cases and literature review.

Congenital tricuspid valve stenosis is extremely rare. We describe 2 cases of patients with adult congenital heart disease with hypoplastic tricuspid valve annulus who were symptomatic from annular- and leaflet-level tricuspid stenosis. The patients underwent transcatheter balloon valvuloplasty with good clinical outcomes. An extensive literature review and analysis of various procedural strategies suggests that percutaneous balloon valvuloplasty may be a reasonable therapeutic choice as a first-line therapy or when open surgical repair is associated with prohibitively high mortality. This procedure can be performed either as a destination therapy or as a bridge to valve replacement.

Transcatheter Aortic Valve Replacement in Bicuspid Versus Tricuspid Aortic Valve Stenosis: Meta-Analysis and Systemic Review.

Because of its anatomic and procedural complexities, bicuspid aortic valve (BAV) has been excluded from previous trials investigating transcatheter aortic valve replacement (TAVR). We aimed to compare the clinical outcomes of TAVR in BAV and tricuspid aortic valve patients. We searched the databases systematically from inception until March 2023 for studies that reported the outcomes of TAVR in BAV and tricuspid aortic valve patients. The primary focus was all-cause mortality at 1 year. Additional outcomes included outcomes at 30-day follow-up. Secondary and subgroup analyses were performed on propensity-matched patients, patients at low surgical risk, and based on the type of transcatheter valve type. We included 30 studies with a total of 193,274 patients who underwent TAVR, of which 14,353 patients had BAV stenosis. The rate of 1-year mortality was lower in the BAV group compared with the tricuspid group with the results reaching statistical significance (odds ratio [OR] 0.86, 95% confidence interval [CI] 0.75 to 0.98, p = 0.02). The rate of 30-day stroke, however, was higher in patients with BAV who underwent TAVR (OR 1.24, 95% CI 1.08 to 1.43, p <0.05). Other 30-day clinical outcomes were similar between the 2 groups. Similar outcomes were observed in secondary analysis of matched populations with less mortality and higher rate of stroke in patients with BAV (OR 0.84, 95% CI 0.72 to 0.96, p = 0.01, and OR 1.38, 95% CI 1.09 to 1.75, p <0.05, respectively). Comparing the outcomes for self-expandable and balloon-expandable valves resulted in similar results. Subgroup analysis of low-surgical-risk patients similarly showed lower 1-year mortality in patients with BAV (OR 0.67, 95% CI 0.50 to 0.91, p = 0.01), without difference in 30-day stroke between the 2 groups (OR 1.24, 95% CI 0.83 to 1.88, p = 0.30). In conclusion, this report indicates that TAVR is safe and feasible in patients with BAV, including patients at low surgical risk. The higher rate of 30-day stroke, however, warrants caution when pursuing TAVR in this population. More studies, specifically randomized trials, are still warranted to further assess the safety and the long-term outcomes in this group.

TAVR in the tricuspid domain: valve-in-valve transcatheter tricuspid valve replacement for bioprosthetic valve degeneration.

We report a novel use of transcatheter aortic valve replacement (TAVR) for valve-in-valve tricuspid valve replacement. A man in his 50s with prohibitive risks for surgical intervention underwent this procedure to improve severe, symptomatic tricuspid stenosis. Though current literature is limited to case reports, the Valve-in-Valve International Database (VIVID) reports similar mortality rates between surgical and transcutaneous replacement. As a novel, off-label procedure, there is limited operator experience. Nonetheless, in non-operative or high-risk patients, similar outcomes are noted in between transcatheter tricuspid valve replacement and surgical replacement. This registry sets the framework for further studies with the possibility of observing outcomes as operator experience increases, while highlighting the feasibility of the procedure.

Predictors of conduction disturbances after transcatheter aortic valve implantation with balloon-expandable valve for bicuspid aortic valve stenosis.

INTRODUCTION: Implantation depth and membranous septum (MS) length have been established as the predictors of new-onset conduction disturbance (CD) after transcatheter aortic valve replacement (TAVR) for tricuspid aortic valve (TAV) stenosis. However, little is known about the predictors with bicuspid aortic valve (BAV). This study investigated the role of MS length and implantation depth in predicting CD following TAVR with a balloon-expandable valve in patients with BAV. METHODS: This retrospective study analyzed 169 patients who underwent TAVR for BAV with balloon-expandable valve, and TAV cohort was established as a control group using propensity score (PS) matching. The primary endpoints were in-hospital new permanent pacemaker implantation (PPI) and new-onset CD (the composite outcome of new-onset left bundle branch block and new PPI). RESULTS: PPI developed in 14 patients (8.3%) and new-onset CD in 37 patients (21.9%) in the BAV cohort. Multivariate analysis revealed severe left ventricle outflow tract (LVOT) calcification (odds ratio [OR]: 5.83, 95% confidence interval [CI]: 1.08-31.5, p = .0407) and implantation depth-MS length (OR: 1.30, 95% CI: 1.12-1.51, p = .0005) as the predictors of new-onset CD within the BAV cohort. The matched comparison between BAV and TAV groups showed similar MS length (3.0 vs. 3.2 mm, p = .5307), but valves were implanted more deeply in the BAV group than in the TAV group (3.9 vs. 3.0 mm, p < .0001). New-onset CD was more frequent in patients who had BAV (22.3% vs. 13.9%, p = .0458). CONCLUSION: The implantation depth-MS length, and severe LVOT calcification predicted new-onset CD following TAVR in BAV with balloon-expandable valve. Among BAV patients, valves were implanted more deeply compared to TAV patients. High deployment technique could be considered to avoid new-onset CD in BAV anatomy.

Pacemaker Lead-induced Tricuspid Valve Stenosis and Reverse Lutembacher Syndrome.

Reverse Lutembacher syndrome is a rare cause of hypoxia characterized by the triad of tricuspid valve stenosis, elevated right atrial pressure, and an interatrial right-to-left shunt. We report a case of pacemaker lead-induced reverse Lutembacher syndrome in a 45-year-old woman who presented with dyspnea. The patient also developed pacemaker lead-induced superior vena cava obstruction accompanied by a right-to-left shunt through systemic-to-pulmonary venous collaterals, which exacerbated the hypoxia. Tricuspid valve replacement using a bioprosthetic valve and patent foramen ovale closure improved her hypoxia.

Outcomes After Transcatheter Aortic Valve Replacement in Bicuspid Versus Tricuspid Anatomy: A Systematic Review and Meta-Analysis.

OBJECTIVES: The aim of this study was to compare the feasibility, safety, and clinical outcomes of transcatheter aortic valve replacement (TAVR) in bicuspid aortic valve (BAV) versus tricuspid aortic valve (TAV) stenosis. BACKGROUND: At present, limited observational data exist supporting TAVR in the context of bicuspid anatomy. METHODS: Primary endpoints were 1-year survival and device success. Secondary endpoints included moderate to severe paravalvular leak (PVL) and a composite endpoint of periprocedural complications; incidence rates of individual procedural endpoints were also explored individually. RESULTS: In the main analysis, 17 studies and 181,433 patients undergoing TAVR were included, of whom 6,669 (0.27%) had BAV. A secondary analysis of 7,071 matched subjects with similar baseline characteristics was also performed. Device success and 1-year survival rates were similar between subjects with BAV and those with TAV (97% vs 94% [P = 0.55] and 91.3% vs 90.8% [P = 0.22], respectively). In patients with BAV, a trend toward a higher risk for periprocedural complications was observed in our main analysis (risk ratio [RR]: 1.12; 95% CI: 0.99-1.27; P = 0.07) but not in the matched population secondary analysis (RR: 1.00; 95% CI: 0.81-1.24; P = 0.99). The risk for moderate to severe PVL was higher in subjects with BAV (RR: 1.42; 95% CI: 1.29-1.58; P < 0.0001) as well as the incidence of cerebral ischemic events (2.4% vs 1.6%; P = 0.015) and of annular rupture (0.3% vs 0.02%; P = 0.014) in matched subjects. CONCLUSIONS: TAVR is a feasible option among selected patients with BAV anatomy, but the higher rates of moderate to severe PVL, annular rupture, and cerebral ischemic events observed in the BAV group warrant caution and further evidence.

Pacemaker lead-induced tricuspid stenosis treated with percutaneous valvotomy.

BACKGROUND: Tricuspid stenosis is an uncommon complication of ventricular pacemaker electrode implantation, with few cases reported in the literature. CASE: We present an 18-year-old male who developed severe tricuspid stenosis 15 years after endocardial VVI pacemaker implantation for complete AV block following a surgically repaired ventricular septal defect. CONCLUSION: In this case we have shown that percutaneous balloon valvuloplasty was performed and successful in treating this complication.

Invasive Hemodynamic Characteristics in Patients Undergoing Transcatheter Tricuspid Valve-In-Valve Implantation for Treatment of Tricuspid Stenosis.

BACKGROUND: We sought to describe invasive hemodynamic measurements in patients with tricuspid stenosis (TS) undergoing transcatheter tricuspid valve-in-valve (TVIV) implantation immediately pre- and postimplantation. Development of TS in patients who have undergone surgical tricuspid valve replacement with a bioprosthetic valve is a serious complication that leads to elevated right atrial (RA) pressures and decreased cardiac output. Transcatheter TVIV implantation is a viable alternative to surgical tricuspid valve replacement, but data on the hemodynamic consequences of TVIV for the treatment of severe TS are currently limited to echocardiographic assessment of Doppler-derived gradients. METHODS: Eleven patients undergoing transcatheter TVIV implantation with moderate to severe bioprosthetic valve stenosis were selected for retrospective review. Right atrial mean pressure, right ventricular (RV) systolic and end-diastolic pressure, mean diastolic RA-RV pressure gradient, pulmonary artery capillary wedge pressure, pulmonary artery systolic, end-diastolic and mean pressures, and pulmonary artery pulsatility index (PAPi) both before and after transcatheter valve placement were collected from catheterization reports. RESULTS: After transcatheter TVIV implantation, the mean TS gradient decreased significantly (P < .01), while the mean RV end-diastolic pressure increased (P = .046). Pulmonary artery pulsatility index also increased as the TS was relieved (P = .039). CONCLUSIONS: Tricuspid valve-in-valve implantation results in immediate relief of TS, leading to increased RV preload with resultant augmentation of RV and pulmonary pressures. Increased PAPi following the procedure demonstrates acute improvement in RV output but remains low due to the failure of the RA pressure to decline significantly immediately following intervention.

Hybrid trans-apical atrioventricular valve-in-valve implantation in Fontan circulation.

Trans-apical approach has been proved successful in failing surgical bio-prosthesis in both mitral and aortic position in adult patients. Recently, valve-in-valve treatments have been applied even in patients with complex congenital heart disease. Here, we report the case of a 32 years old lady with left atrial isomerism, complete AV septal defect, interrupted inferior vena cava with azygos continuation who underwent Kawashima procedure with atrial Fontan. Severe systemic atrioventricular valve regurgitation necessitated a 33 mm Perimount valve implantation and conversion to lateral tunnel Fontan. After only 4 years there was severe valve stenosis and the patient underwent successful trans-apical transcatheter implantation of a 29 mm Sapien valve.

Vector Flow Imaging of the Ascending Aorta in Patients with Tricuspid and Bicuspid Aortic Valve Stenosis Treated with Biological and Mechanical Implants.

Aortic valve stenosis (AS) is treated with biological prostheses (BPs) and mechanical prostheses (MPs). Vector flow imaging (VFI), an angle-independent ultrasound method, can quantify flow complexity (vector concentration (VC)) and secondary rotation (SR). Ten patients (mean age: 70.7 y) with tricuspid AS scheduled for BPs, 10 patients (mean age: 56.2 y) with bicuspid AS scheduled for MPs and 10 patients (mean age: 63.9 y) with normal aortic valves were scanned intra-operatively on the ascending aorta with VFI and conventional spectral Doppler. Bicuspid AS (peak systolic velocity (PSV): 380.9 cm/s, SR: 16.7 Hz, VC: 0.21) had more complex flow (p < 0.02) than tricuspid AS (PSV: 346.1 cm/s, SR: 17.1 Hz, VC: 0.33). Both groups had more complex and faster flow (p < 0.0001) than normal aortic valve patients (PSV: 124.0 cm/s, SR: 4.3 Hz, VC: 0.79). VC (r = 0.87) and SR (r = 0.89) correlated to PSV. After surgery, flow parameters changed (p < 0.0001) for patients with MPs (PSV: 250.4 cm/s, SR: 9.8 Hz, VC: 0.54) and BPs (PSV: 232.4 cm/s, SR: 12.5 Hz, VC: 0.61), with MPs having slower SR (p < 0.01). None of the implants had normal flow (p < 0.0001). In conclusion, VFI can provide new flow parameters for AS and implant assessment.

Differences in Flow-Gradient Patterns Between Severe Bicuspid Aortic Stenosis and Severe Tricuspid Aortic Stenosis　- Mechanistic Insight From Multimodal Imaging.

BACKGROUND: We investigated the flow-gradient pattern characteristics and associated factors in severe bicuspid aortic stenosis (AS) compared with severe tricuspid AS.Methods and Results:A total of 252 patients with severe AS (115 bicuspid vs. 137 tricuspid) who underwent aortic valve (AV) replacement were retrospectively analyzed. Patients were classified into 4 groups according to stroke volume index and mean pressure gradient across the AV [normal-flow-high-gradient (NF-HG), low-flow-high-gradient, normal-flow-low-gradient, low-flow-low-gradient (LF-LG)]. In 89 patients who underwent cardiac computed tomography (CT), influential structural parameters of the left ventricular outflow tract (LVOT), AV and ascending aorta were assessed. Bicuspid AS was more likely to present a NF-HG pattern (83.5% vs. 64.2%, P<0.001), and significantly fewer presented a LF-LG pattern compared with tricuspid AS. In bicuspid AS, there was a significant mismatch between geometric orifice area (GOA) on CT planimetry and effective orifice area (EOA) calculated using the echocardiographic continuity equation. Bicuspid AS presented with a larger angle between the LVOT-AV and aorta. Multivariate analysis of bicuspid AS revealed that systemic arterial compliance (ß=-0.350, P=0.031) and the LVOT-AV-aorta angle (ß=-0.538, P=0.001), and stroke volume index (ß=0.409, P=0.008) were associated with a discrepancy between GOA and EOA. CONCLUSIONS: Flow-gradient patterns in bicuspid AS differ from those of tricuspid AS and are associated with the structural and functional characteristics of the aorta.

Transcatheter Tricuspid Valve-in-Valve Replacement Via Right Internal Jugular Vein Access in a 39-Year-Old Woman.

Transcatheter tricuspid valve-in-valve replacement via right internal jugular is safe and feasible for failed bioprosthetic valve implantation. Challenging aspects include stiff wire advancement into the pulmonary artery for rail establishment and multiple push-pull manipulations for balloon and valve advancement.

Surgical valvulotomy for tricuspid valve stenosis in a dog.

A 2-year, 4-month-old neutered female Labrador retriever was brought for evaluation of right-sided congestive heart failure. Echocardiographic examination revealed tricuspid valve dysplasia with only two small orifices in the valve resulting in severe tricuspid stenosis. The dog underwent a right fifth lateral intercostal thoracotomy and surgical tricuspid valvulotomy, under cardiopulmonary bypass. The stenosis was relieved by dividing the valve leaflets between the two orifices with continuation to the commissures, creating a 'bileaflet' valve. The dog made a good recovery initially, with echocardiography at 48 h after surgery showing a reduction in tricuspid valve E and A wave velocities and pressure half-time (from 230 ms to 65 ms). She was discharged five days after surgery, and spironolactone, benazepril, pimobendan, and clopidogrel were prescribed. The dog was re-presented two days later having collapsed, with pyrexia, facial swelling, and pitting edema on the ventral neck and intermandibular region. Investigations did not reveal an underlying cause, and the clinical signs resolved with supportive therapy. Two years after surgery, the dog was free of clinical signs with normal exercise tolerance and only mild tricuspid regurgitation on echocardiography, with discontinuation of all medications.

Single-session double valve replacement: TAVI+tricuspid valve-in-valve procedures.

We describe a 70-year-old lady with rheumatic heart disease and a history of the mitral valve and tricuspid valve replacement, who underwent transcatheter aortic valve implantation and the tricuspid valve-in-valve procedure in a single session.

Etiology of tricuspid valve disease is a predictor of bradyarrhythmia after tricuspid valve surgery.

AIMS: The tricuspid valve is situated in close proximity to cardiac conduction tissue and damage to this tissue can affect postoperative rhythm. The aim of this study was to quantify the incidence of pacemaker requirement after tricuspid valve surgery and investigate predictors. METHODS: Data were collected via our operative data collection system and patient files. All patients who underwent surgical procedures of the tricuspid valve from 2004 until 2017 and lacked a pacemaker preoperatively were included in the study. RESULTS: In our cohort of 505 patients 54 required a pacemaker in the first 50 days after surgery. We calculated a 17.5% (95% confidence interval [CI], 13.5-21.3) risk of pacemaker implantation at 4 years postoperatively. Multivariate analysis identified preoperative active endocarditis (odds ratio 3.17; CI, 1.32-7.65; P = 0.010) and "inadequate pacemaker dependent rhythm" (defined as any intrinsic heart rate below 45 per minute requiring pacing) upon admission to the intensive care unit after surgery (odds ratio 5.924; CI, 2.82-12.44; P = 0.001) as predictors for pacemaker requirement in the first 50 days after surgery. Twenty-six pacemakers (48%) were implanted for atrioventricular block, 16 (30%) for sinus node dysfunction and 12 (22%) for atrial fibrillation. Kaplan-Meier analysis showed no difference in survival between the pacemaker and no pacemaker group. CONCLUSION: Surgery of the tricuspid valve has a high burden of postoperative pacemaker requirement. Preoperative active endocarditis and the initial postoperative rhythm are predictors. Understanding this allows for better decision-making regarding further medical/device therapy.

Tricuspid valve disease: diagnosis, prognosis and management of a rapidly evolving field.

Tricuspid valve disease, and particularly tricuspid regurgitation, is a highly prevalent condition with a complex pathophysiology and long-term adverse consequences. Although historically neglected, tricuspid valve disease has gained increasing recognition, with important advances in the assessment and management of this disorder over the past 2 decades. Surgical treatment remains the standard of care, but it continues to have one of the the highest death rates among all cardiac valve-related procedures, and a broad range of patients still do not receive effective therapy for tricuspid valve disease in contemporary clinical practice. Therefore, several alternative, less-invasive technologies for treating patients with severe, native tricuspid valve disease at high surgical risk have been developed in the past decade, with promising early results. This Review summarizes key findings and highlights the latest developments in the diagnosis and management framework that are transforming clinical practice in the complex field of tricuspid valve disease.