Transcatheter Tricuspid Valve-in-Valve Implantation for the Treatment of Dysfunctional Surgical Bioprosthetic Valves

Abstract

Background— Off-label use of transcatheter aortic and pulmonary valve prostheses for tricuspid valve-in-valve implantation (TVIV) within dysfunctional surgical tricuspid valve (TV) bioprostheses has been described in small reports. Methods and Results— An international, multicenter registry was developed to collect data on TVIV cases. Patient-related factors, procedural details and outcomes, and follow-up data were analyzed. Valve-in-ring or heterotopic TV implantation procedures were not included. Data were collected on 156 patients with bioprosthetic TV dysfunction who underwent catheterization with planned TVIV. The median age was 40 years, and 71% of patients were in New York Heart Association class III or IV. Among 152 patients in whom TVIV was attempted with a Melody (n=94) or Sapien (n=58) valve, implantation was successful in 150, with few serious complications. After TVIV, both the TV inflow gradient and tricuspid regurgitation grade improved significantly. During follow-up (median, 13.3 months), 22 patients died, 5 within 30 days; all 22 patients were in New York Heart Association class III or IV, and 9 were hospitalized before TVIV. There were 10 TV reinterventions, and 3 other patients had significant recurrent TV dysfunction. At follow-up, 77% of patients were in New York Heart Association class I or II ( P <0.001 versus before TVIV). Outcomes did not differ according to surgical valve size or TVIV valve type. Conclusions— TVIV with commercially available transcatheter prostheses is technically and clinically successful in patients of various ages across a wide range of valve size. Although preimplantation clinical status was associated with outcome, many patients in New York Heart Association class III or IV at baseline improved. TVIV should be considered a viable option for treatment of failing TV bioprostheses.

Rapid Pacing Using the Guidewire During Transcatheter Tricuspid Valve in Valve Implantation

“…In the VIVID registry [9], which is a large international registry of TTVI, rapid pacing during valve implantation was used mostly during Sapien valve implantation. Pacing was performed through existing leads or with a temporary pacing catheter/ wire, most often introduced retrogradely into the left ventricle or coronary sinus.…”

“…There are several reports of transcatheter tricuspid "valve-in-valve" and "valve-inring" implantations with reasonable short-and medium-term results [8,9].…”

“…Although the lower pressure in the right ventricle may reduce the need for rapid pacing during valve implantation, it is used in most cases when the Sapien valve is implanted [8,9]. Rapid pacing is usually done using the patient's permanent pacemaker or a temporary pacing electrode.…”

“…Rapid pacing is usually done using the patient's permanent pacemaker or a temporary pacing electrode. The pacing electrode is usually introduced retrogradely into the left ventricle or coronary sinus; other positions used are the right atrium or right ventricle [8,9]. Placing a pacing electrode in the left ventricle requires additional arterial access.…”

Transcatheter Valve-in-Valve Implantation for Failing Bioprosthetic Triscupid Valves

“…However, the number of patients treated with tricuspid VIV replacement has remained small. In this issue of Circulation, McElhinney and colleagues 12 evaluate the outcomes of VIV procedures for patients who present with surgical bioprosthetic tricuspid valve dysfunction. The number of patients presenting with this problem, even to large medical centers, is low; therefore, the authors need to be congratulated on their efforts to establish this voluntary international registry, thereby accumulating the largest experience reported in this field thus far.…”