Single-Session Transcatheter Aortic and Tricuspid Valve-in-Valve Implantation in a Patient with Prior Multivalve Surgery and a Chronic Transvenous Pacing Lead: A Case-Based Review of Procedural Strategy

Figures

• 

  Figure 1. Preprocedural transthoracic echocardiography (apical views). (A) Continuous-wave Doppler across the tricuspid bioprosthesis, showing a mean gradient of 7 mmHg (peak velocity 2.1 m/s), consistent with severe prosthetic stenosis. (B) Continuous-wave Doppler across the native aortic valve, showing a peak velocity of 4.56 m/s and a mean gradient of 47 mmHg; pulsed-wave Doppler of the left ventricular outflow tract (LVOT) is shown alongside for continuity-equation calculation of an aortic valve area of 0.75–0.76 cm2, consistent with critical aortic stenosis. (C) Continuous-wave Doppler across the mechanical mitral prosthesis, showing a mean gradient of 9 mmHg, consistent with moderate prosthetic stenosis. *** bpm = beats per minute.

• 

  Figure 2. Preprocedural cardiac computed tomography—multiplanar reconstruction used for sizing and calcium assessment of the native aortic valve. (A) Annular measurements: minimum diameter 22.1 mm, maximum diameter 28.5 mm, average diameter 25.3 mm, area-derived diameter 25.2 mm, perimeter-derived diameter 25.6 mm, area 497.7 mm2, perimeter 80.4 mm. (B) Volume-rendered short-axis (“hockey-puck”) view of the aortic root at the level of the valve, showing the non-coronary (NC) and left coronary (LC) cusps. (C) Three-dimensional quantification of aortic valve calcification.

• 

  Figure 3. Tricuspid bioprosthesis sizing and its spatial relationship with the pacing lead. (A) Axial CT reconstruction showing the tricuspid bioprosthetic sewing ring and its spatial relationship with the ventricular pacing lead. (B) Multiplanar CT reconstruction illustrating the relationship between the tricuspid bioprosthesis and the ventricular pacing lead. (C) Double-oblique multiplanar reconstruction used for anatomical measurements, showing a tricuspid valve annulus area of 7.3 cm2; distance 2, measured from the sewing ring to the right ventricular apex, was 63.1 mm, and distance 3, measured from the tricuspid valve sewing ring to the roof of the right atrium, was 91.2 mm. (D) Volume-rendered reconstruction illustrating the three-dimensional spatial relationship between the tricuspid bioprosthesis and the ventricular pacing lead.

• 

  Figure 4. Procedural fluoroscopic imaging. (A) Balloon inflation under rapid ventricular pacing during transcatheter aortic valve implantation. (B) Simultaneous fluoroscopic visualization of both INNOWI guidewires positioned in the left and right ventricles (biventricular guidewire strategy). (C) Balloon expansion of the reverse-mounted tricuspid valve-in-valve prosthesis.

• 

  Figure 5. Final procedural and echocardiographic results. (A) Fluoroscopic image showing the three prosthetic valves (aortic, mechanical mitral, and tricuspid) together with the permanent right ventricular pacing lead. (B) Pre-discharge transthoracic echocardiography, apical four-chamber view, with continuous-wave Doppler across the tricuspid valve-in-valve prosthesis, showing a markedly reduced mean gradient of 4 mmHg and trivial residual regurgitation compared with the severe pre-procedural stenosis in Figure 1A. (C) Pre-discharge transthoracic echocardiography, apical five-chamber view, with continuous-wave Doppler across the transcatheter aortic valve, showing a mean gradient of 9 mmHg compared with the critical pre-procedural stenosis in Figure 1B. *** bpm = beats per minute.

• 

  Figure 6. Proposed practical algorithm for combined transcatheter aortic and tricuspid valve-in-valve intervention. Green boxes indicate the pathway followed in the present case; amber diamonds indicate decision points; grey boxes indicate alternative or staged pathways; blue boxes indicate standard steps or recommendations. Section numbers in parentheses indicate where the supporting evidence for each step is discussed in the text.