Transcatheter Valve-In-Valve Implantation in Patients With Fluoroscopically Invisible Tricuspid Valve Prostheses

Figures

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  Figure 1. Guidewire Placement and Predilatation in Patient 1 (A) CT image showing the tricuspid bioprosthesis and its distance to the RCA. (B) A guidewire is placed in the RCA (yellow arrows) in preparation for predilatation with a balloon (white arrow). A temporary left ventricular electrode for rapid pacing is also visible in the coronary sinus (blue arrow). (C) The predilatation is performed with the guidewire in the RCA (yellow arrows). The white arrow points to the waist of the balloon and the location of the degenerated and radiographically invisible prosthetic valve. (D) The projection angle is corrected so that the guidewire (yellow arrows) is approximately at the beginning of the balloon waist during predilatation. CT = computed tomography; RCA = right coronary artery.

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  Figure 2. Valve Positioning, Implantation, and Hemodynamic Outcome in Patient 1 (A) The proximal end of the new valve (white arrow) is almost overlapping with the RCA guidewire (yellow arrows). (B) The transcatheter valve is in place (white arrow). The guidewire in the RCA (yellow arrows) marks its proximal end, which also corresponds to the proximal end of the surgically implanted valve. (C) Preimplantation and (D) postimplantation invasive hemodynamic measurements. RCA = right coronary artery.

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  Figure 3. Preprocedural Radiographic Findings in Patient 2 (A) A right ventriculogram with a pigtail catheter. The tricuspid valve prosthesis is not visualized; the white arrows point to its supposed location. Note the severely enlarged right ventricle. (B) Preprocedural hemodynamic measurements in the right atrium (yellow tracing) and right ventricle (red tracing). A diastolic gradient is clearly seen (dashed area).

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  Figure 4. RCA Placement and Predilatation in Patient 2, and Postprocedural Outcome (A) A coronary guidewire is placed in the RCA (yellow arrows) to mark the location of the tricuspid valve prosthesis at the waist of the balloon (white arrow) during tricuspid balloon valvuloplasty. (B) Transcatheter valve-in-valve implantation is performed with the RCA guidewire (yellow arrows) in place to mark the landing zone for the new valve (white arrow). (C) Postimplantation right ventriculogram with the new valve in place (white arrow). No tricuspid regurgitation is visible. (D) Single-chamber pacemaker in AAI mode with a right atrial electrode (white arrow) was implanted owing to sinoatrial block. AAI = atrial single-chamber pacing; RCA = right coronary artery.

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  Figure 5. Balloon Valvuloplasty of a Severely Stenosed Tricuspid Valve Prosthesis The white arrows are pointing toward the waist of the balloon, where the tricuspid prosthesis should be located.

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  Figure 6. Ballon Predilatation and Implantation Using RCA References in Patient 3, and Postprocedural Outcome In all images, the yellow arrows indicate the guidewire in the RCA, and the white arrow points to the waist of the balloon. (A) Balloon predilatation is performed with a coronary guidewire placed in the RCA to mark the location of the tricuspid valve prosthesis at the waist of the balloon. (B) The projection angle is corrected so that the guidewire is approximately at the beginning of the balloon waist. (C) The balloon-expandable valve is slowly implanted while the guidewire in the RCA serves as a reference. (D) Right ventriculogram after valve implantation does not show any tricuspid regurgitation. The RCA guidewire is still in place. RCA = right coronary artery.