Percutaneous Transcatheter Balloon Valvuloplasty for Bioprosthetic Tricuspid Valve Stenosis
A 59-year-old woman was admitted to our hospital because of exertional dyspnea, abdominal distension, and leg edema over the past 2 weeks. She had a history of rheumatic fever at the age of 12 years. In 1983, at the age of 37, she had undergone tricuspid valve replacement with a Carpentier-Edwards bioprosthesis for tricuspid stenosis and mitral valve replacement with a mechanical valve for mitral stenosis. The physical examination on admission revealed marked edema in both legs. There was also presystolic pulsation of the liver, which was palpable 4 cm below the right costal margin. A Levine grade III/VI, rough, diastolic rumble at the lower left sternal border was accentuated during inspiration. Echocardiography revealed severe tricuspid stenosis and a large amount of ascites. The leaflets were thickened, shortened, and immobile, resulting in a fixed orifice in systole and diastole. The mean diastolic gradient across the tricuspid valve was 14.1 mm Hg, with a peak gradient of 23.0 mm Hg during early diastole (Figure 1A). Tricuspid regurgitation was mild (Figure 1B and online-only Data Supplement Movie I), and there was no aortic or mitral valve pressure gradient. Initial therapy consisted of a diuretic for right-sided heart failure, but it did not relieve her ascites or leg edema. Therefore, we performed percutaneous transcatheter balloon valvuloplasty to reduce the gradient across the bioprosthetic tricuspid valve (Figure 2A and 2B and Movies II and IIII). During right heart catheterization, the right atrial tracing revealed a prominent A wave (24 mm Hg), with a mean diastolic gradient across the tricuspid valve of 13 mm Hg (Figure 2C). After the balloon valvuloplasty, the mean diastolic gradient across the tricuspid valve decreased to 6 mm Hg (Figure 2D). Echocardiography showed that the mean diastolic gradient across the tricuspid valve decreased to 7.0 mm Hg without worsening of tricuspid regurgitation (Figure 1C and 1D and Movie IV). The patient’s symptoms immediately improved and the ascites disappeared. The present report demonstrates the successful use of percutaneous transcatheter balloon valvuloplasty for bioprosthetic tricuspid valve stenosis.
The online-only Data Supplement, which includes 4 movies, is available with this article at http://circ.ahajournals.org/cgi/content/full/114/18/e558/DC1.