Transcatheter valve-in-ring and para-ring vascular plug implantation for severe tricuspid regurgitation following annuloplasty ring failure: a case report

Abstract

Background Moderate or severe tricuspid regurgitation (TR) recurs in up to one-third of patients within 8 years of surgical annuloplasty repair. Reoperation often carries high risk with poor outcomes. Transcatheter valve-in-ring repair is an emerging alternative treatment. However, residual regurgitation is frequent and may necessitate further procedures. Case summary A 52-year-old female was diagnosed with severe rheumatic valvular heart disease. The patient underwent mechanical aortic and mitral valve replacement. Additionally, tricuspid repair was performed using a semi-rigid annuloplasty ring (28 mm Edwards Physio Tricuspid). Within 2 years, the patient developed recurrent, isolated severe symptomatic TR, with progressive right ventricular dilatation. The patient was considered prohibitive risk for redo surgery and unsuitable for cardiac transplantation. She underwent percutaneous valve-in-ring transcatheter heart valve implantation (THV) using a 29 mm Sapien S3 (Edwards Lifesciences, California, USA) valve. Persistent severe residual para-ring TR warranted a further procedure to deploy vascular plugs, significantly reducing the TR to a mild jet with symptomatic improvement. Discussion Valve-in-ring THV implantation for failed surgical tricuspid annuloplasty repair is a rare procedure reserved for symptomatic patients at high or prohibitive risk for reoperation. Significant residual TR is a commonly encountered problem with incomplete annuloplasty rings following valve-in-ring procedures and may occur either intra-ring between the THV and the ring or para-ring. Implantation of vascular occlusion devices can be used to successfully treat residual TR at either location with good outcomes at 6-month Follow-up. Further work is required to determine the longevity of this treatment.

Paravalvular Leak Closure After Transcatheter Tricuspid Valve-in-Ring Implantation: A Case Report

“…Transcatheter innovations remain the perfect solution for patients with symptomatic recurrence of severe TR deemed at high risk of mortality for redo surgery. Despite the off-label indication of using transcatheter technologies over the TV, there are several case reports of successful TVIR implantation [10][11][12][13]. However, PVL remains an inevitable complication that may be more severe in some cases compared to others, depending on the position of the newly implanted valve and the type of ring used in the previous repair.…”

“…Data regarding PVL closure post-TVIR is limited to some case reports where vascular plugs or VSD occluders were used [ 10 - 13 ]. Here, we demonstrated the successful closure of a large PVL using a dedicated rectangular Occlutech PVL device measuring 18 mm x 10 mm.…”

Transjugular tricuspid valve‐in‐ring replacement using the novel system under three‐dimensional printing guidance

“…Additionally, PVL and the severe intra-ring regurgitation that resulted from the nonconformity between the orifice areas Transjugular tricuspid valve-in-ring replacement using the novel system under three-dimensional printing guidance of the prosthesis and the rigid ring will be removed by the giant atrial disc, which completely overlays the dilated TA (Figure 4F). 9 The transcatheter tricuspid valve replacement device with radial force-independent fixation has been shown in previous clinical studies to be effective; therefore, it is not essential to select an oversize when implanting the prosthesis, which also facilitates a corresponding change in the annulus diameter during right ventricular remodelling. 10,11 All the points above were found out by preoperative simulation and postoperative assessment using patient-specific 3D models.…”

“…Of note, the three stress points formed by two anchoring pins and an intraventricular anchorage enclose a uniformly distributed stress area in the shape of a triangle to ensure the stability of the stent ( Figure ). Additionally, PVL and the severe intra‐ring regurgitation that resulted from the nonconformity between the orifice areas of the prosthesis and the rigid ring will be removed by the giant atrial disc, which completely overlays the dilated TA ( Figure ) 9 . The transcatheter tricuspid valve replacement device with radial force‐independent fixation has been shown in previous clinical studies to be effective; therefore, it is not essential to select an oversize when implanting the prosthesis, which also facilitates a corresponding change in the annulus diameter during right ventricular remodelling 10,11 .…”