Acute Hemodynamic Instability After Transcatheter Tricuspid Valve Replacement

Figures

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  Visual Summary. Hemodynamic Phenotyping in Patients Presenting With AHI After TTVR: 3 Main Patterns AHI after TTVR, excluding any significant procedural complications (eg, bleeding, structural injury, high-grade conduction disturbances), could be related to 3 clinical patterns: afterload mismatch, right ventricular failure, and SIRS-related vasoplegia. The main hemodynamic characteristics of each entity are represented here. AHI = acute hemodynamic instability; BP = blood pressure; LVOT SV = left ventricular outflow tract stroke volume; RVSP = right ventricular systolic pressure; SIRS = systemic inflammatory response syndrome; TTVR = transcatheter tricuspid valve replacement.

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  Figure 1. Afterload Mismatch: Patient 1 The left panels represent the most relevant baseline characteristics. The right side shows the postprocedural RV pressure waveform corresponding to a “pulsus alternans” aspect. A hemodynamic simulation of postprocedural status using Harvi software is depicted in the lower right corner, showing the predictable major RV afterload increase after TTVR based only on preprocedural status. PV = pressure-volume; RV = right ventricular; TTVR = transcatheter tricuspid valve replacement.

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  Figure 2. Harvi Software Workflow: A Patient-Specific Simulation The patient's baseline imaging and hemodynamic characteristics are entered in the online platform. Simulation of the intervention is achieved by removing the tricuspid regurgitation effective regurgitant orifice area (TR EROA). The predicted post-TTVR pressure-volume loop appears in the bottom right corner. RV = right ventricular; TTVR = transcatheter tricuspid valve replacement.

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  Figure 3. Intrinsic RV Failure: Patient 2 Baseline ostial right coronary artery (RCA) lesion is shown on the left side. A simulation of the expected postinterventional right ventricular hemodynamics, without significant RCA disease, is represented on the right panel. The hatched part on the graph corresponds to the increase in pressure-volume area (PVA) compared with baseline. This simulation shows the anticipated increase in PVA, a surrogate for myocardial oxygen consumption, which supports the hypothesis of supply-demand mismatch in the presence of ostial RCA stenosis. Abbreviations as in Figure 1.

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  Figure 4. SIRS-Induced Vasoplegia: Patient 3 Representation of the chronology and the mechanistic pathway of hypotension in the setting of procedure-induced SIRS. SIRS = systemic inflammatory response syndrome; TTVR = transcatheter tricuspid valve replacement.