Clinical Images

Transcatheter Tricuspid Valve-in-Valve Replacement Via Right Internal Jugular Vein Access in a 39-Year-Old Woman

Puja B. Parikh, MD1;  Robert Pyo, MD2;  Kathleen Stergiopoulos, MD, PhD1;  Jordan Katz, MD1;  Roger Fan, MD1;  Igor Izrailtyan, MD2;  Thomas Bilfinger, MD3

Puja B. Parikh, MD1;  Robert Pyo, MD2;  Kathleen Stergiopoulos, MD, PhD1;  Jordan Katz, MD1;  Roger Fan, MD1;  Igor Izrailtyan, MD2;  Thomas Bilfinger, MD3

J INVASIVE CARDIOL 2019;31(10):E304-305.

Key words: bioprosthetic tricuspid valve stenosis, transcatheter tricuspid valve replacement

A 39-year-old woman with severe bioprosthetic tricuspid valve (TV) stenosis (Figure 1A) presented with worsening dyspnea and peripheral edema. At age 17, she had a septic abortion with endocarditis and underwent surgical TV replacement (TVR) with a 33 mm Carpentier-Edwards prosthesis. At age 29, she underwent re-do surgical TVR with another 33 mm Carpentier-Edwards prosthesis for bioprosthetic TV stenosis.  Given multiple prior surgeries, the heart team concurred that transcatheter tricuspid valve-in-valve replacement (TTVR) via the right internal jugular (RIJ) vein would be most suitable.

The patient was intubated and general anesthesia was induced. A decapolar catheter was placed in the coronary sinus via femoral vein access. A 7 Fr sheath was inserted into the RIJ and exchanged to a 21 Fr Certitude sheath (Edwards Lifesciences). A Swan-Ganz catheter was advanced to the pulmonary artery (PA) with a Glidewire (Terumo) to cross the TV bioprosthesis. Given inability to advance a Lunderquist wire (Cook Medical) through the Swan-Ganz catheter, an Amplatz Extra-Stiff wire (Cook Medical) was instead inserted into the PA. The Swan-Ganz catheter was exchanged for a coronary guide catheter through which the Lunderquist wire was successfully advanced. A 20 mm Ascendra balloon (Edwards Lifesciences) was advanced by pushing the delivery catheter and pulling the stiff wire simultaneously (“push-pull”). Following valvuloplasty (Figure 1B), a 29 mm Edwards Sapien 3 valve (Edwards Lifesciences) loaded in reverse fashion was advanced across the TV with multiple push-pull manipulations (Figures 1C and 1D). The valve was successfully deployed (with additional 4 mL beyond nominal inflation) with rapid pacing (Figure 1E). TEE demonstrated no paravalvular leak and gradient of 3 mm Hg. The delivery system, wire, and sheath were removed and the incision was closed. Patient was discharged home the next day with low-molecular-weight heparin and warfarin. 

TTVR via RIJ is safe and feasible for failed bioprosthetic TV. The most challenging aspects are stiff wire advancement into the PA for “rail” establishment and multiple push-pull manipulations for balloon and valve advancement.

From the 1Department of Medicine, 2Department of Anesthesia, and 3Department of Surgery, Stony Brook University Hospital, Stony Brook, New York.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein. 

The authors report that patient consent was provided for publication of the images used herein.

Manuscript accepted March 6, 2019.

Address for correspondence: Puja B. Parikh, MD, MPH, FACC, FAHA, FSCAI, Co-Director, Transcatheter Aortic Valve Replacement Program, Stony Brook University Medical Center, Health Sciences Center T16-080, Stony Brook, NY 11794-8160. Email: