Orthotopic Transcatheter Tricuspid Valve Replacement After Heterotopic Caval Valve Failure

Figures

• 

  Visual Summary. The Upper Panels Summarize the Patient’s Clinical History and Presentation After Previous TricValve Implantation for Severe Tricuspid Regurgitation The central panels illustrate the evidence of TricValve degeneration, with dysfunction of the inferior caval valve prosthesis characterized by loss of leaflet coaptation, cusp prolapse, and recurrent regurgitant flow toward the inferior vena cava. The lower panels depict the subsequent transcatheter treatment strategy with Evoque transcatheter tricuspid valve replacement. MVR = mitral valve replacement; TEER = transcatheter edge-to-edge repair.

• 

  Figure 1. TEE Assessment of Native Tricuspid Valve and Degenerated TricValve Color Doppler transesophageal echocardiography (TEE) demonstrating torrential central tricuspid regurgitation (A and B). Large central coaptation gap measuring up to 14 mm (C) and evidence of tricuspid annular dilation (D). Bicaval TEE views of the previously implanted TricValve prosthesis at the inferior vena cava. White arrow indicates the prosthetic cusp degeneration and prolapse (E), associated with severe prosthetic regurgitation (F) on color Doppler imaging. LA = left atrium; PAZ = ; RA = right atrium; RV = right ventricle; S = septal; SVC = superior vena cava.

• 

  Figure 2. Preprocedural Computed Tomography Planning for Transcatheter Tricuspid Valve Replacement Computed tomography reconstruction of the tricuspid annulus in diastole (A) and systole (B), demonstrating annular dimensions, perimeter, and area measurements used for device sizing. Computed tomography-based assessment of right ventricle septo-lateral dimensions in diastole (C) and systole (D). Spatial relationship of the previously implanted inferior vena cava TricValve prosthesis with the right atrium (RA) anticipating possible interactions with the transcatheter tricuspid valve replacement delivery system (E), including measurement of prosthetic extension into the RA (F). AP = antero-posterior; TV = tricuspid valve.

• 

  Figure 3. Evoque Implantation Positioning of the Safari guidewire in the right ventricle apex across the tricuspid valve through a steerable catheter after right femoral venous access (A). Advancement of the Evoque delivery system across the previously implanted inferior vena cava TricValve prosthesis without significant interaction or resistance and tricuspid valve crossing (B). Stepwise deployment of the Evoque valve (C and D). Final valve release after confirmation of correct native leaflet engagement, appropriate positioning of the anchoring elements, and absence of significant interference with the previously implanted caval prostheses (E and F). Final transesophageal echocardiography demonstrating a well-functioning Evoque prosthesis with no paravalvular leak and only trace residual central tricuspid regurgitation (G). Continuous-wave Doppler assessment showing normal postprocedural transvalvular gradients (H). ICE = intracardiac echocardiography; LA = left atrium; MV = mitral valve; VTI = velocity time integral; other abbreviations as in Figure 1.