Excerpt

A 49-year-old woman with history of implantation of pacemaker with surgical epicardial lead placement due to complete heart block followed by upgrade to cardiac resynchronization therapy, four previous surgical tricuspid valve replacements due to degenerative valve failure and endocarditis, left ventricular ejection fraction of 20%, and heart failure due to long history of right ventricular pacing, atrial flatter, and possible inadequate myocardial protection in several cardiac surgeries presented with moderate-to-severe regurgitation of the 25-mm Mosaic bioprosthetic valve. Based on computed tomography, actual measurement of inner diameter of 25-mm Mosaic bioprosthetic valve was measured manually (and also Valve-in-Valve app; http://​www.​ubqo.​com/​ViV is helpful), and a 23-mm SAPIEN 3 valve was planned with the heart team approach. Procedure was performed via the percutaneous, transvenous femoral approach under general anesthesia and with ICE guidance. The 8-Fr AcuNav catheter was placed into right atrium (RA). The SAPIEN 3 valve was then deployed by slow balloon inflation under fluoroscopy and with ICE guidance (Fig. 1a, b; Online Video 1). Pre- and postprocedural valve functions including paravalvular leak were evaluated using the ICE catheter (Fig. 1c, d; Online Video 2, 3). She was discharged on the 9th postoperative days after paracentesis and readjustment of diuretics. This is the first report that demonstrates the utility of ICE imaging in patients undergoing the ViV procedure in tricuspid position [1]. ICE provided excellent visualization during ViV, and was very helpful for positioning of the transcatheter valve due to the Mosaic bioprostheses lacking a clearly visible fluoroscopic sewing ring marker. With improvement in transcatheter valves and delivery systems, many centers have advocated for angiographic-based minimalist approach without general anesthesia with intermittent transthoracic echocardiography. Ideally, in this case, it must be transcatheter tricuspid valve-in-valve implantation under ICE guidance without intubation in terms of minimalist approach. Due to lack of experience and immature heart team, patient was intubated just in case ICE is suboptimal for this procedure. Nonetheless, clearly, better resolution imaging with continuous monitoring can be obtained when ICE is utilized compared with transthoracic echocardiography alone. Moreover, ICE can be an acceptable alternative to transesophageal echocardiography (TEE) and a much less invasive option in the tricuspid ViV procedure, because general anesthesia will not be required [2]. ICE can obtain the optimal perpendicular imaging plane easily for pre- and postprocedural assessment such as device positioning, paravalvular leak, and transvalvular gradient, which provides the information to decide if additional interventions are required. In this case, as shown in Fig. 1d, there was no paravalvular leak postprocedure. She already had mean gradient of 9 mmHg just after the surgical tricuspid valve replacement in 2013, even though valve leaflets open well. After ViV procedure at this time, she had mean gradient of 6 mmHg on invasive measurement. Her valve area was 1.6 cm² (index 0.93 cm²/BSA). Basically, 25-mm Mosaic is small for tricuspid position; however, there was heavily calcified annulus and that was the largest valve that we could surgically replace. Furthermore, at the time of surgery in 2013, the surgeon considered the potential transcatheter procedure in a future and decided to have tissue valve rather than mechanical valve, which usually has wider valve area. Currently, there is no standard definition of prosthesis patient mismatch on tricuspid valve. However, she had improvement clinically, meaning that it is relatively small valve for her, but it is clinically acceptable.

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