Background. Transcatheter tricuspid valve-in-valve replacement for patients with degenerative tricuspid surgical bioprosthesis disease has emerged in recent years as a new treatment possibility in patients that required tricuspid valve replacement at young age and in circumstances where redo tricuspid valve replacement is not feasible because of the remarkable morbidity and mortality.
Case presentation. A 76 year-old Caucasian male was referred to our center for worsening dyspnoea and fatigue. He had a pacemaker implanted for third degree atrio-ventricular block in 1996. After massive endocarditis affecting the tricuspid valve and the pacemaker right ventricular lead, the patient underwent surgical tricuspid valve replacement with a 32 mm Liotta BioImplant L.P.B., right ventricular lead extraction and concomitant epicardial pacemaker reimplantation. Transthoracic echocardiogram at hospital admission denoted a degenerative stenosis of the tricuspid prosthesis with a trans-valvular mean gradient of 8 mmHg associated with right atrial and inferior vena cava dilatation. Given the high surgical risk due to comorbidities (systemic arterial hypertension, paroxysmal atrial fibrillation in DOAC, grade II obesity, smoking history and chronic lymphoproliferative leukemia) the patient was deemed not suitable for a re-do surgical tricuspid valve replacement and was offered a percutaneous replacement. Preprocedural planning with computed tomography allowed accurate reconstruction of the tricuspidal prosthetic annulus and correct sizing of Edwards SAPIEN valve, the most used in valve-in-valve procedures. The degenerated prosthesis was not visible at fluoroscopy meaning no fluoroscopic landmarks available to provide an anatomic view for valve deployment. Therefore, a combination of balloon valvuloplasty and right atrium angiographies before the valve-in-valve deployment were critical to provide the correct valve position and yield the procedure effective and safe. Hemodynamic gradient post-TVIV was absent and no paravalvular leaks were observed. Clinical and echocardiographic improvement were confirmed after the procedure and at 1 year-follow up.
Conclusion. Tricuspid valve-in-valve replacement can be technically feasible and a safer alternative to re-do surgical valve replacement, also in radiolucent bioprosthesis. In our case the successful procedural outcome not only relied on meticulous planning before the procedure, but also on specific intra-procedural adjustments.