The bioprosthetic valve has become the main choice for tricuspid valve replacement because of its advantages such as low incidence of thrombosis and avoidance of complications associated with anticoagulation [
In August 2019, a 48-year-old male presented at our hospital due to severe dyspnea (NYHA III), cyanosis, dizziness, peripheral edema, hepatauxe, and massive ascites. He had a history of the congenital ventricular septal defect, infective endocarditis, heart valve infective vegetation, and severe tricuspid valve regurgitation and undergone ventricular septal defect repair, aortic valve repair, pulmonary valve repair, and the tricuspid valve replacement with a 29 mm bioprosthesis (Edwards Lifesciences, LLC; Irvine, California) in another hospital in 2005. Severe postoperative pulmonary infection complications occurred and required tracheotomy and ventilator-assisted therapy for more than seven days. From the beginning of 2017, he gradually started to present heart failure symptoms and underwent multiple hospital admissions for severe dyspnea, peripheral edema, and recurrent ascites. The current physical examination revealed lethargy, cyanotic lips, jugular vein distension, a grade of 2/6 diastolic murmur at the left lower sternal border, hepatauxe, and massive ascites. Blood gas analysis shows that oxygen pressure is 56.8 mmHg, oxygen saturation is 88.2%, carbon dioxide is 27.6 mmHg, and hemoglobin is 231 g/L.
Transthoracic echocardiography revealed bioprosthetic TV stenosis (Figure
Transthoracic echocardiography (TTE) and Doppler before the operation: bioprosthetic tricuspid valve calcification (white arrow) and stenosis (a, b). Bioprosthetic maximal velocity 2.7 m/s (c). The foramen ovale opening (white arrow) (d).
Cardiac computed tomography images: distribution of severe bioprosthetic leaflet calcification (a). Inner diameter of the bioprosthetic valve (26.3 mm) (b). The best projection angles (c).
After the interdisciplinary assessment, the heart team decided to perform transcatheter tricuspid VIV implantation using the J-valve system because of a significantly increased surgical risk for conventional redo surgery: the estimated surgical risks (EuroSCORE II) were 12.4%. Based on MDCT measurements, the 27 mm J-valve was suitable for valve-in-valve replacement in the tricuspid position.
After confirmed consent and Hospital Ethics Committee approval (no. 20190009) were obtained, the procedure was performed in a hybrid operating room under general anesthesia with a double-lumen endotracheal tube. Transesophageal echocardiogram (TEE) was used for the evaluation of the valve pathology and operation result. Both the right femoral artery and vein were exposed for emergency cardiopulmonary bypass. The left radial artery and right internal jugular vein puncture catheterization was performed for measurement of blood pressure and central venous pressure. A right minithoracotomy in the fourth intercostal space and the right atrial double purse-string sutures were performed according to the coaxial position of the tricuspid annulus. Heparin was administered to keep the activated clotting time at more than 300 seconds. After the right atrium puncture, a soft guide wire and then a superstiff guide wire were used to cross the bioprosthetic valve and into the right ventricle. The valvuloplasty (balloon inflated to 22 mm, Percutaneous Transluminal Valvuloplasty Catheter Z-MED II™, NuMED, CAN) was performed without rapid ventricular pacing. The J-valve was reversely loaded on the conveyor system and successfully implanted into the degenerated bioprosthesis. The three “U-shape graspers” were released and embraced the prior bioprosthetic struts (Figure
Step-by-step transatrial TVIV implantation of the J-valve. The right atrium puncture according to the coaxial position of the tricuspid annulus (a). The three “U-shape graspers” were released and embraced the prior bioprosthetic struts (white arrow) (b). Full deployment of the J-valve (c).
Postoperatively, oral warfarin anticoagulation was used to maintain an internationalization ratio of 2.0-2.5 for three months. Transthoracic echocardiography and electrocardiogram were performed regularly for postoperative evaluation. Thirty-four months after surgery, the patient was free of heart failure symptoms and the echocardiogram suggested excellent hemodynamics of the bioprosthetic valve (Figure
The transthoracic echocardiogram images during the 34-month follow-up period: TTE showed optimal valve position and well hemodynamic status (a, b). TTE with color flow showed a maximal velocity of 1.6 m/s (c).
Transcatheter VIV implantation has become an attractive option for failed aortic and mitral bioprostheses. The American Food and Drug Administration approved the mitral VIV procedure with the Edwards SAPIEN system in 2017 [
The J-valve is a new generation self-expendable valve and has previously been shown to be effective for the treatment of both serve aortic valve stenosis and aortic regurgitation. A J-valve multicenter study, which enrolled 107 high-risk patients with aortic valve stenosis, aortic valve regurgitation, or bicuspid aortic valve (BAV), demonstrated a lower rate of complications and mortality at 1-year follow-up [
Transcatheter tricuspid VIV implantation has become an acceptable alternative to conventional open surgery for patients with a failed tricuspid bioprosthesis. This case demonstrated that transcatheter VIV replacement using a J-valve system may be a new option for the failed tricuspid bioprosthesis patients.
The data generated or analyzed during this study in this published article are available from the corresponding author on reasonable request.
The authors declare that they have no conflicts of interest.