Transcatheter Tricuspid Valve Replacement for Torrential Tricuspid Regurgitation in Complex Adult Congenital Heart Disease

Figures

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  Figure 1. Preprocedural Cardiac Magnetic Resonance Imaging Preprocedural cardiac magnetic resonance imaging 4-chamber (horizontal long axis) view demonstrating pacing lead in the right atrium passing through the tricuspid valve (left image, long arrow); the tricuspid valve (short arrow); and the broad jet of tricuspid regurgitation on flow imaging (right image, dashed arrow). RV = right ventricle.

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  Figure 2. Preprocedural Cardiac Computed Tomography With Multiplanar Reconstruction, Acquired as a Rotational “Spin” About the Tricuspid Valve to Define the Relationship of the Pacemaker Lead to the Valve (Left) Long-axis reconstruction through the right atrium and right ventricle. (Right) Orthogonal short-axis reconstruction through the right and left ventricles, demonstrating the pacing lead crossing the posteroseptal commissure of the tricuspid valve and embedding in the right ventricular septum. LAO = left anterior oblique; MPR = multiplanar reconstruction; RAO = right anterior oblique.

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  Figure 3. Intraprocedural Fluoroscopy in the Right Anterior Oblique Projection (RAO 30°) During Transcatheter Tricuspid Valve Replacement With the EVOQUE System, Captured at the Anchor-Exposure Step The EVOQUE delivery system, advanced over a Safari wire, lies across the tricuspid valve between the right atrium (RA) and right ventricle (RV), with the device anchors exposed before leaflet capture and valve release. The pre-existing permanent pacemaker (PPM) lead is seen traversing the right heart.

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  Figure 4. Final Fluoroscopic Acquisition in the Right Anterior Oblique Projection (RAO 30°) Following Deployment of a 48 mm EVOQUE Valve, Which is Well-Seated Within the Tricuspid Annulus Between the RA and RV The pre-existing permanent pacemaker (PPM) lead is jailed against the annulus by the device frame. Abbreviations as in Figure 3.

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  Visual Summary. Transcatheter Tricuspid Valve Replacement in Complex Adult Congenital Heart Disease (ACHD) The visual summary illustrates the clinical presentation, Heart Team decision-making, procedural challenges, and early outcomes following transcatheter tricuspid valve replacement with a 48-mm EVOQUE valve in a patient with complex ACHD and torrential tricuspid regurgitation. Despite distorted right heart anatomy and a transvalvular pacing lead, successful valve implantation was achieved with mild residual tricuspid regurgitation, preserved pacing system function, and early symptomatic and functional improvement. PA = pulmonary artery; RA = right atrium; RV = right ventricle; TEE = transesophageal echocardiography; TEER = transcatheter edge-to-edge repair; TOF = tetralogy of Fallot; TR = tricuspid regurgitation; TTVR = transcatheter tricuspid valve replacement; VSD = ventricular septal defect.