Treatment of severe tricuspid regurgitation induced by permanent pacemaker lead: Transcatheter tricuspid valve replacement with the guidance of 3-dimensional printing

Figures

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  Figure 1. Assessment of TEE and CTA before TTVR evaluated the status of TV (e.g., data for patient #6) assessment of RA and RV using circle cardiovascular imaging CVI42 software. (A) TEE showed large regurgitation on TV. (B) The maximum velocity of TV was up to 1.1 m/s. (C, D) The area of the RA was 4071.9 mm2, and the area of the RV was 1748.4 mm2. The yellow arrows indicate the lead of the permanent pacemaker. TEE, transesophageal echocardiography; CTA, computed tomography angiography; TTVR, transcatheter tricuspid valve replacement; TV, tricuspid valve; RA, right atrium; RV, right ventricle; TA, tricuspid annulus.

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  Figure 2. Introduction of LuX-valve. (A, B) LuX-valve (Ningbo Jenscare Biotechnology, Ningbo, China) consists of a biological valve stent, three valve lobules, and a steerable delivery system. The bioprosthesis is implanted via the RA approach and fixed in the TA with its own unique anchoring device, independent of the radial support force. It consists of an atrium disc, annulus skirt and anchored blade.

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  Figure 3. Preoperative 3D reconstruction and 3D-printed models of all 6 patients to help surgeons understand anatomical structures and make an accurate surgical plan. (A) The process of 3D reconstruction using Materialise Mimics version 21.0 (Materialise, Leuven, Belgium). (B) 3D-printed models of all 6 patients’ right cardiac systems in the RA view. The yellow arrow heads to the lead of the permanent pacemaker. RA, right atrium; 3D, 3-dimensional.

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  Figure 4. Simulation of TTVR using a 3D-printed model on the bench test (e.g., data for patient #6). (A) The delivery system was entered into the RA through the superior vena cava. (B) The delivery system was positioned to the TA, and the depth and coaxiality were adjusted. (C) The atrium disc began to be released. (D) The atrium disc was fully released. (E) IVA and two clamping keys were released in turn. (F) The delivery system was withdrawn. (G) RA view of TV after simulation. (H) RV view of TV after simulation. TTVR, transcatheter tricuspid valve replacement; RA, right atrium; TA, tricuspid annulus; RV, right ventricle; IVA, interventricular anchor; TV, tricuspid valve.

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  Figure 5. TEE and DSA were guided for TTVR. (A) DSA showed severe TR on TV. (B) The LuX-Valve system guided by TEE was used to deliver the prosthesis to the tricuspid annulus through the right intercostal approach. (C) The delivery system first released IVA and two graspers, and TEE guided the anterior leaflet of the tricuspid valve to be clamped by the grasper. (D) The annulus skirt and atrium disc were released in turn, and the position of the implant was adjusted by TEE guidance to ensure that there was no obvious paravalvular leakage. (E) The prosthesis was completely released after fixation with IVA. (F) Postoperative TEE showed that TR disappeared immediately. TEE, transesophageal echocardiography; DSA, digital subtracted angiography; TR, tricuspid regurgitation; TV, tricuspid valve; IVA, interventricular anchor.

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  Figure 6. The postoperative 3D reconstruction and 3D-printed models of all 6 patients verified the position of the stented valve, and the lead remained attached to the RV with no change in threshold after the valve was implanted. (A) 3D printed model of the patient's right cardiac system in the RA view. (B) 3D printed model of the patient's right cardiac system in the RV view. RA, right atrium; RV, right ventricle; 3D, 3-dimensional.

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  Figure 7. 2-year follow-up results showed reduced TR severity and improved clinical, functional, and quality-of-life outcomes. (A) Assessment of TR severity. P value from Wilcoxon signed rank test. (B) Comparison of NYHA functional class between pre-procedures and 2-year follow-up. P value from Wilcoxon signed rank test. (C) Comparison of 6MWD distance. P value from paired Student's t-test. (D) Assessment of KCCQ score. P value from paired Student's t-test. TR, tricuspid regurgitation; 6MWD, 6-min walk distance; KCCQ, Kansas City cardiomyopathy questionnaire; NYHA, New York heart association.