Transcatheter Tricuspid Valve Replacement for Severe Tricuspid Regurgitation Post–Left Ventricular Assist Device

Figures

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  Figure 1. Transthoracic Echocardiographic Evaluation of Tricuspid Regurgitation and Right Ventricular Function Pre–Left Ventricular Assist Device Implantation (A) Right ventricular inflow view with continuous wave Doppler interrogation of the tricuspid valve demonstrating a peak tricuspid regurgitant velocity (TR Vmax) of 2.52 m/s. (B) Apical four-chamber (A4C) view with continuous wave Doppler interrogation of the tricuspid valve demonstrating a peak tricuspid regurgitant velocity (TR Vmax) of 2.86 m/s. (C) Representative color Doppler image of the tricuspid valve. (D) Right atrial area measured at 31.49 cm2. (E) Right ventricular outflow tract velocity time integral of 9.50 cm. (F) Right ventricle S' velocity measured at 13.3 cm/s. (G) Tricuspid annular planar systolic excursion measured at 2.09 cm/s. (H) Right ventricular global longitudinal strain of −18.4%.

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  Figure 2. Right Heart Catheterization Pre– and Post–EVOQUE Placement (A) Right heart catheterization tracings, and (B) right heart catheterization values. Hemodynamic data obtained via right heart catheterization. Hemodynamics were obtained on LVAD support at the following settings: speed = 5,400 rpm, flow = 5.1 L/min, PI = 1.9, and power = 3.8 W. CO/CI = cardiac output (L/min) and cardiac index (L/min/m2) by Fick method; CVP = central venous pressure; DPG = diastolic pulmonary gradient (mm Hg); eFick CO/CI = estimated Fick cardiac output/index; HR = heart rate (beats/min); LVAD = Left ventricular assist device; LVAD parameters = speed (rpm), flow (L/min), pulsatility index (PI), and power (W); MAP = mean arterial pressure (mm Hg); LPM = liters per minute; PA = pulmonary artery pressure (mm Hg); PAP = pulmonary artery pressure; PA compliance (SV/PP) = stroke volume/pulmonary pulse pressure; PA saturation = pulmonary artery oxygen saturation (%); PAPi = pulmonary artery pulsatility index; PCWP = pulmonary capillary wedge pressure (mm Hg); PI = pulsatility index; PVR = pulmonary vascular resistance (Wood units); RA = right atrial pressure (mm Hg); RA: PCWP = ratio of right atrial to…

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  Figure 3. Step-by-Step Technique of Transcatheter Tricuspid Valve Replacement Under Fluoroscopic and Transthoracic Echocardiography Guidance (A) Guidewire placement across the tricuspid valve in the RV with the EVOQUE valve delivery system at the right atrial/inferior vena cava (RA-IVC) junction. (B) Fluoroscopic demonstration of the capsule gap. (C) Device orientation. (D) Ventricular expansion. (E) Deployment of the EVOQUE valve. (F) Guidewire advanced across the tricuspid valve position confirmed without entanglement of cardiac structures on transthoracic echocardiography. (G-I) Incremental release of the EVOQUE valve with the leaflet capture on transthoracic echocardiography. (J) Complete deployment of the EVOQUE valve within the tricuspid annulus on 3-dimensional planimetry. RV = right ventricle.

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  Figure 4. Arterial Pressure Tracing Pre– and Post–EVOQUE Transcatheter Tricuspid Valve Replacement Deployment Arterial pressure tracing pre– and post–EVOQUE transcatheter tricuspid valve replacement deployment. The red arrow denotes the time of transcatheter tricuspid valve replacement EVOQUE valve deployment.

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  Figure 5. Transthoracic Echocardiography 6 Months Post–Transcatheter Tricuspid Valve Replacement (A) Right ventricular inflow view demonstrating adequate position of the EVOQUE valve. (B) Subxiphoid view demonstrating adequate position of the EVOQUE valve. (C) Apical four-chamber (A4C) view demonstrating adequate position of the EVOQUE valve. (D) Right ventricular inflow view with continuous wave Doppler (TTVR Vmax: 1.53 m/s; TTVR Vmean: 0.8 m/s; TTVR PG: 9 mm Hg, TTVR MG: 3 mm Hg). (E) Apical four-chamber (A4C) with continuous wave Doppler (TTVR Vmax: 1.53 m/s; TTVR Vmean: 0.9 m/s; TTVR PG: 9 mm Hg TTVR MG: 4 mm Hg). (F) Apical 4-chamber view with pulsed-wave Doppler (TTVR peak E velocity: 1.40 m/s; TTVR PG: 9 mm Hg). (G) Interrogation of hepatic vein via pulsed wave Doppler denoting absence of systolic flow reversal. MG = mean transprosthetic tricuspid inflow gradient; PG = peak transprosthetic tricuspid inflow gradient; TTVR = transcatheter tricuspid valve replacement; Vmax = peak transprosthetic tricuspid inflow velocity; Vmean = mean transprosthetic tricuspid inflow velocity.

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  Visual Summary. TTVR as a Rescue Strategy for Severe TR and Refractory RVF Post-LVAD Implantation Image created with Biorender.com. CVP = central venous pressure; LVAD = left ventricular assist device; RV = right ventricle; RVF = right ventricular failure; TR = tricuspid regurgitation; TTVR = transcatheter tricuspid valve replacement.