Effectiveness of balloon valvuloplasty for stenosis of a bioprosthesis in the tricuspid valve position Adam M. Falcone, MD, Joji J. Varghese, MD, Robert C. Stoler, MD, and James W. Choi, MD
a
b
Figure 1. Simultaneous pressure readings in the right atrium and right ventricle (a) before balloon valvuloplasty, with a mean gradient of 9 mm Hg, and (b) after balloon valvuloplasty, with a mean gradient of 5 mm Hg.
A 67-year-old man underwent percutaneous balloon valvuloplasty for bioprosthetic tricuspid stenosis. He had undergone two tricuspid valve replacements over a period of 39 years and became symptomatic. After the valvuloplasty, his symptoms were resolved. Stenosis of a bioprosthetic tricuspid valve can be successfully and safely treated with balloon valvuloplasty.
CASE DESCRIPTION A 67-year-old man was referred for evaluation for possible percutaneous balloon valvuloplasty because of stenosis of a bioprosthesis in the tricuspid valve position. The patient had originally undergone excision of a right atrial myxoma and tricuspid valve replacement by Dr. Denton Cooley at the age of 28. At the age of 55, his fatigue increased and lowerextremity edema worsened. The stenotic bioprosthesis in the tricuspid valve was replaced again with a 25 mm CarpentierEdwards pericardial bioprosthesis. Over the past year, he had been experiencing increasing amounts of lower-extremity 502
edema, fatigue, and ascites. Echocardiography disclosed a mean gradient of 15 mm Hg across the bioprosthetic tricuspid valve. The patient did not wish to undergo a third sternotomy and was referred to our institution. Examination disclosed sinus rhythm, 2/6 diastolic murmur loudest over the left sternal border, hepatosplenomegaly, ascites, and trace tibial edema. Right-sided cardiac catheterization via the right femoral vein disclosed a 9 mm Hg gradient between the right atrium and right ventricle (Figure 1a). A 0.035 inch, 260 cm long J-tipped wire was placed into the left pulmonary artery, which allowed a 25 mm × 4 cm Z-Med II Balloon (Braun Interventional Systems, Bethlehem, PA) to be placed across the bioprosthetic From the Division of Cardiology, Baylor Heart and Vascular Hospital, Dallas, Texas (Falcone, Stoler, Choi); Hedrick Cardiology, Abilene, Texas (Varghese); and Texas A&M College of Medicine (Choi). Corresponding author: James W. Choi, MD, Cardiology Consultants of Texas, 621 North Hall Street, Suite 400, Dallas, TX 75226 (e-mail: James.Choi@ baylorhealth.edu). Proc (Bayl Univ Med Cent) 2015;28(4):502–503
Table 1. Previously published reports of balloon valvuloplasty of a stenotic bioprosthesis in the tricuspid valve position
First author
Mean RA-RV gradient (mm Hg)
Valve type
Balloon type
Pre
Post
Yunoki (1)
13
6
C-E
Unknown
Unknown
Petrou (2)
13
6
C-E
Inoue
Died 2 months later
Reddy (3)
16
12
Mosaic 29 mm
Nucleus-X NYHA Class II symptoms at 6 weeks
Härle (4)
7
2
Unknown Tyshak II
Outcome
NYHA Class I symptoms at 6 months
C-E indicates Carpentier-Edwards; NYHA, New York Heart Association; RA, right atrium; RV, right ventricle.
Figure 2. Inflation of 25 mm Z-Med II balloon in the bioprosthetic tricuspid valve.
tricuspid valve. Once inflation was complete, the mean pressure gradient was reduced to 5 mm Hg (Figures 1b and 2). Postprocedure transthoracic echocardiography showed that the mean gradient was reduced from 9 mm Hg to 6 mm Hg. The patient tolerated the procedure well and was discharged home the following day. At 3-month follow-up, his fatigue, ascites, and peripheral edema had resolved. DISCUSSION Percutaneous balloon valvuloplasty is commonly used to treat patients with aortic and mitral stenosis. Our patient with
October 2015
a stenotic bioprosthetic tricuspid valve was treated with balloon valvuloplasty. This has been previously reported, and data from these cases are summarized in Table 1. 1. Yunoki K, Naruko T, Itoh A, Ohashi J, Fujimoto K, Shirai N, Shimamura K, Koatsu R, Skanoue Y, Haze K. Percutaneous transcatheter balloon valvuloplasty for bioprosthetic tricuspid valve stenosis. Circulation 2006;114:e558–559. 2. Petrou E, Vartela V, Girasis C, Boutsikou M, Iakovou I, Pavlides G. Balloon valvuloplasty for bioprosthetic tricuspid valve stenosis. Korean Circ J 2014;44(2):128–129. 3. Reddy G, Ahmed M, Alli O. Percutaneous valvuloplasty for severe bioprosthetic tricuspid valve stenosis in the setting of infective endocarditis. Catheter Cardiovasc Interv 2015;85(5):925–929. 4. Härle T, Kronberg K, Motz R, Elsässer A. Balloon valvuloplasty of a tricuspid valve stenosis in double balloon technique. Clin Res Cardiol 2010;99(3):203–205.
Effectiveness of balloon valvuloplasty for stenosis of a bioprosthesis in the tricuspid valve position
503
a
b
Figure 1. Simultaneous pressure readings in the right atrium and right ventricle (a) before balloon valvuloplasty, with a mean gradient of 9 mm Hg, and (b) after balloon valvuloplasty, with a mean gradient of 5 mm Hg.
A 67-year-old man underwent percutaneous balloon valvuloplasty for bioprosthetic tricuspid stenosis. He had undergone two tricuspid valve replacements over a period of 39 years and became symptomatic. After the valvuloplasty, his symptoms were resolved. Stenosis of a bioprosthetic tricuspid valve can be successfully and safely treated with balloon valvuloplasty.
CASE DESCRIPTION A 67-year-old man was referred for evaluation for possible percutaneous balloon valvuloplasty because of stenosis of a bioprosthesis in the tricuspid valve position. The patient had originally undergone excision of a right atrial myxoma and tricuspid valve replacement by Dr. Denton Cooley at the age of 28. At the age of 55, his fatigue increased and lowerextremity edema worsened. The stenotic bioprosthesis in the tricuspid valve was replaced again with a 25 mm CarpentierEdwards pericardial bioprosthesis. Over the past year, he had been experiencing increasing amounts of lower-extremity 502
edema, fatigue, and ascites. Echocardiography disclosed a mean gradient of 15 mm Hg across the bioprosthetic tricuspid valve. The patient did not wish to undergo a third sternotomy and was referred to our institution. Examination disclosed sinus rhythm, 2/6 diastolic murmur loudest over the left sternal border, hepatosplenomegaly, ascites, and trace tibial edema. Right-sided cardiac catheterization via the right femoral vein disclosed a 9 mm Hg gradient between the right atrium and right ventricle (Figure 1a). A 0.035 inch, 260 cm long J-tipped wire was placed into the left pulmonary artery, which allowed a 25 mm × 4 cm Z-Med II Balloon (Braun Interventional Systems, Bethlehem, PA) to be placed across the bioprosthetic From the Division of Cardiology, Baylor Heart and Vascular Hospital, Dallas, Texas (Falcone, Stoler, Choi); Hedrick Cardiology, Abilene, Texas (Varghese); and Texas A&M College of Medicine (Choi). Corresponding author: James W. Choi, MD, Cardiology Consultants of Texas, 621 North Hall Street, Suite 400, Dallas, TX 75226 (e-mail: James.Choi@ baylorhealth.edu). Proc (Bayl Univ Med Cent) 2015;28(4):502–503
Table 1. Previously published reports of balloon valvuloplasty of a stenotic bioprosthesis in the tricuspid valve position
First author
Mean RA-RV gradient (mm Hg)
Valve type
Balloon type
Pre
Post
Yunoki (1)
13
6
C-E
Unknown
Unknown
Petrou (2)
13
6
C-E
Inoue
Died 2 months later
Reddy (3)
16
12
Mosaic 29 mm
Nucleus-X NYHA Class II symptoms at 6 weeks
Härle (4)
7
2
Unknown Tyshak II
Outcome
NYHA Class I symptoms at 6 months
C-E indicates Carpentier-Edwards; NYHA, New York Heart Association; RA, right atrium; RV, right ventricle.
Figure 2. Inflation of 25 mm Z-Med II balloon in the bioprosthetic tricuspid valve.
tricuspid valve. Once inflation was complete, the mean pressure gradient was reduced to 5 mm Hg (Figures 1b and 2). Postprocedure transthoracic echocardiography showed that the mean gradient was reduced from 9 mm Hg to 6 mm Hg. The patient tolerated the procedure well and was discharged home the following day. At 3-month follow-up, his fatigue, ascites, and peripheral edema had resolved. DISCUSSION Percutaneous balloon valvuloplasty is commonly used to treat patients with aortic and mitral stenosis. Our patient with
October 2015
a stenotic bioprosthetic tricuspid valve was treated with balloon valvuloplasty. This has been previously reported, and data from these cases are summarized in Table 1. 1. Yunoki K, Naruko T, Itoh A, Ohashi J, Fujimoto K, Shirai N, Shimamura K, Koatsu R, Skanoue Y, Haze K. Percutaneous transcatheter balloon valvuloplasty for bioprosthetic tricuspid valve stenosis. Circulation 2006;114:e558–559. 2. Petrou E, Vartela V, Girasis C, Boutsikou M, Iakovou I, Pavlides G. Balloon valvuloplasty for bioprosthetic tricuspid valve stenosis. Korean Circ J 2014;44(2):128–129. 3. Reddy G, Ahmed M, Alli O. Percutaneous valvuloplasty for severe bioprosthetic tricuspid valve stenosis in the setting of infective endocarditis. Catheter Cardiovasc Interv 2015;85(5):925–929. 4. Härle T, Kronberg K, Motz R, Elsässer A. Balloon valvuloplasty of a tricuspid valve stenosis in double balloon technique. Clin Res Cardiol 2010;99(3):203–205.
Effectiveness of balloon valvuloplasty for stenosis of a bioprosthesis in the tricuspid valve position
503
