Balloon Valvuloplasty of a Stenosed Bioprosthetic Tricuspid Valve
Percutaneous balloon valvuloplasty is rarely used in stenotic bioprosthetic valves, especially in the tricuspid position. A 72-year-old woman presented with right heart failure and was found to have a stenosed tricuspid bioprosthetic valve with thickened and fused cusps with an estimated valve area of 1 cm2 (Figure 1; Movie). She had undergone 2 previous open heart surgeries 19 and 20 years previously: first aortic valve replacement (Bjork-Shiley prosthesis, Shiley, Inc, Irvine, Calif) and mitral valvotomy, and then mitral valve replacement (31-mm St Jude prosthesis, St Paul, Minnesota) and tricuspid valve replacement (33-mm MMI pericardial bioprosthesis). The gradient through the bioprosthetic tricuspid valve was 12 mm Hg on hemodynamic measurement (Figure 2), right ventricular pressure was 32/11 mm Hg, and pulmonary arterial pressure was 36/15 mm Hg.
She was not willing to have another cardiac operation and underwent percutaneous valvuloplasty of her tricuspid valve bioprosthesis. This was carried out under general anesthesia, and the valve was dilated sequentially by using a 15-mm balloon followed by 25- and 30-mm balloons, using echocardiography and fluoroscopy (Figure 3 and Figure 4). There were no immediate complications, and no significant tricuspid regurgitation was induced. The tricuspid gradient was 5 mm Hg on hemodynamic measurements immediately after dilation (Figure 5). She was discharged in stable condition and remained well on follow-up.
Repeat surgical valve replacement has significant morbidity and mortality rates. Percutaneous balloon valvuloplasty may be a reasonable therapeutic alternative for stenotic bioprosthetic valves in the tricuspid position. The long-term outcome of such a procedure remains unclear, with the need for further experience and longer-term follow-up.
The Movie is available in the online-only Data Supplement at http://circ.ahajournals.org/cgi/content/full/113/18/e745/DC1.