Transcatheter Valve-in-Valve Implantation and PFO Closure for Acute Leaflet Thrombosis After Transcatheter Tricuspid Valve Replacement

BACKGROUND: Early leaflet thrombosis is a recognized complication following transcatheter tricuspid valve replacement (TTVR), with potential hemodynamic consequences including transvalvular obstruction and elevated right-sided pressures. CASE SUMMARY: An 82-year-old woman with a history of TTVR with a 56-mm EVOQUE system presented with breathlessness and hypoxia. Imaging demonstrated near-circumferential hypoattenuated leaflet thickening consistent with acute leaflet thrombosis, resulting in increased transvalvular gradients and right-to-left shunting across a patent foramen ovale (PFO). She underwent transcatheter heart valve (THV)-in-TTVR implantation with concomitant PFO closure, resulting in significant clinical improvement. DISCUSSION: Early thrombosis after TTVR may elevate right atrial pressure and result in intracardiac shunting through a previously clinically silent PFO, causing refractory hypoxemia. Combined structural intervention, including PFO closure and THV-in-TTVR, represents a feasible management strategy in hemodynamically significant cases. TAKE-HOME MESSAGES: THV-in-TTVR is a feasible rescue therapy for clinically significant leaflet thrombosis. Further evidence to define optimal antithrombotic regimens following TTVR is required.