Transcatheter Tricuspid Valve-in-Valve

Intervention for Degenerative Bioprosthetic

Tricuspid Valve Disease
Fabien Praz, MD, Isaac George, MD, Susheel Kodali, MD, Konstantinos P. Koulogiannis, MD, Linda D. Gillam, MD,
Mary Z. Bechis, MD, David Rubenson, MD, Wei Li, MD, and Alison Duncan, MRCP, PhD, New York, New York;
Morristown, New Jersey; La Jolla, California; and London, United Kingdom

Isolated reoperative tricuspid valve replacement is one of the highest risk operations classified in the Society of
Thoracic Surgeons registry, particularly in the setting of preexisting right ventricular dysfunction. Transcath-
eter tricuspid valve-in-valve implantation represents an attractive alternative to redo surgery in patients with
tricuspid bioprosthetic valve degeneration who are considered high-risk or unsuitable surgical candidates.
In this review article, the authors discuss the emergence of transcatheter tricuspid valve-in-valve therapy, pre-
procedural echocardiographic assessment of tricuspid bioprosthetic valve dysfunction, periprocedural imag-
ing required for tricuspid valve-in-valve implantation, and postprocedural assessment of tricuspid
transcatheter device function. (J Am Soc Echocardiogr 2018;31:491-504.)

Keywords: Transcatheter, Tricuspid, Valve-in-valve, Degenerative bioprosthetic tricuspid valve

Transcatheter valve-in-valve (ViV) procedures are attractive alternatives real-time (RT) three-dimensional (3D) transthoracic echocardiographic
to redo conventional surgery to treat dysfunctional aortic1 and mitral2 and transesophageal echocardiographic (TEE) images of the normal and
bioprostheses. Until recently, transcatheter tricuspid valve (TV) implan- diseased TV, to permit early and accurate detection of TV disease, to
tation within either an existing surgical bioprosthesis (tricuspid ViV im- direct the timing and assess the effectiveness of treatment, to guide
plantation) or a previously repaired TV had been limited to small case transcatheter TV interventions, and to assess residual TV disease.
series or case reports.3-12 However, with the recent publication of the
global transcatheter tricuspid Valve-in-Valve International Database
(VIVID) registry,13 and recognition that redo surgery for failing TV bio- ANATOMIC CONSIDERATIONS AND IMPLICATIONS FOR TV
prosthesis carries increased morbidity and mortality, particularly when SURGERY
preexisting right ventricular (RV) dysfunction is present,14-17 it is likely
that tricuspid ViV procedures will become an increasingly recognized The TV apparatus is composed of three leaflets (anterior, posterior, and
alternative to redo surgical TV intervention. Moreover, novel septal) attached to the myocardium of the right ventricle either directly
transcatheter techniques to repair native regurgitant TVs are also or by the means of chordae linked to a papillary muscle. Autopsy
emerging.18-21 Facilitation of successful transcatheter TV procedures studies, however, report highly variable anatomy; in one study, the
requires comprehensive understanding of two-dimensional (2D) and TV was found to be a single leaflet in 17% of cases, bicuspid in 72%,
and tricuspid in only 17%, with the posterior leaflet being frequently
either absent or incorporated into the anterior or septal leaflets.22
From the Structural Heart & Valve Center, New York Presbyterian/Columbia Other studies report absent septal papillary muscle23 or presence of
University Medical Center, New York, New York (F.P., I.G., S.K.); Morristown
accessory leaflets24 in a high proportion of human hearts. In tricuspid
Medical Center, Morristown, New Jersey (K.P.K., L.D.G.); Division of
regurgitation (TR), anatomic distortion may be accentuated by multiple
Cardiovascular Diseases, Scripps Clinic, La Jolla, California (M.Z.B., D.R.); and
Royal Brompton Hospital, London, United Kingdom (W.L., A.D.).
chordal attachments between the myocardium and valve leaflets, re-
sulting in secondary leaflet tethering with RV dilatation. This process
Dr. Praz and Dr. Kodali are consultants for Edwards Lifesciences (Irvine, CA).
is aggravated by volume overload, which results not only in TV distor-
Reprint requests: Alison Duncan, MRCP, PhD, Royal Brompton Hospital, Royal
tion but progressive deterioration in RV systolic function. As a result,
Brompton and Harefield NHS Foundation Trust, Sydney Street, London SW3
6NP, United Kingdom (E-mail: a.duncan@rbht.nhs.uk).
severe TV disease has been associated with a threefold increase in
all-cause mortality rate and a four- to fivefold increased incidence of
Attention ASE Members:
cardiac events during long-term follow-up,25 while elective tricuspid
The ASE has gone green! Visit www.aseuniversity.org to earn free continuing annuloplasty for patients with functional TR undergoing elective left-
medical education credit through an online activity related to this article. sided heart surgery is associated with a reduction in cardiac-related
Certificates are available for immediate access upon successful completion mortality and improved echocardiographic outcomes.26
of the activity. Nonmembers will need to join the ASE to access this great Because of the anatomic complexity of the TV and coexisting
member benefit! advanced RV disease, almost 30% of patients are deemed unsuit-
able for surgical TV repair at presentation and are instead offered
0894-7317/$36.00 TV replacement.27 Although robust comparative data are unavai-
Copyright 2017 by the American Society of Echocardiography. All rights reserved. lable,28,29 implantation of a bioprosthesis is preferred in current
http://dx.doi.org/10.1016/j.echo.2017.06.014 practice.27 In addition, the increased bleeding risk associated
491
492 Praz et al Journal of the American Society of Echocardiography
April 2018

Abbreviations
with long-term oral anticoagula- Table 1 Doppler parameters of prosthetic TV function:
tion and mechanical valve current American Society of Echocardiography guidelines
2D = Two-dimensional replacement can be avoided. A
3D = Three-dimensional recently published meta-analysis Consider TV stenosis*
of observational studies showed †
CW = Continuous-wave Peak velocity >1.7 m/sec
no differences between mechani-
cal and biologic TV replacement Mean gradient† $6 mm Hg
EOA = Effective orifice area
in terms of survival and re- PHT $230 msec
IVC = Inferior vena cava operation. However, the risk for EOA and VTIPrTV/VTILVOT ‡

LOE = Level of evidence valve thrombosis was significantly PrTV, Prosthetic TV.
higher in patients with mechanical *Average more than five cycles to account for respiratory variation.
LVOT = Left ventricular
prostheses.30 For reasons still un- †
May also be increased with valvular regurgitation. Reprinted from
outflow tract
clear, the longevity of tricuspid Zoghbi et al.40
‡
MSCT = Multislice computed bioprostheses seems shorter Although the current guidelines for the echocardiographic assessment
tomography compared with that of bio- of TV prostheses do not include cutoffs for EOA and VTIPrTV/VTILVOT,
prostheses exposed to the sys- Blauwet et al.41 published data on a large series (N = 285) of a number
PHT = Pressure half-time
temic circulation (aortic, mitral). of TV prosthesis models and sizes that include proposed cutoffs for these
RT = Real-time This translates into a reoperation hemodynamic variables.

RV = Right ventricular rate of about 20% for valve

confirmed in multiple case reports and series.35 The largest series pub-
degeneration within 10 years
TEE = Transesophageal lished to date, the tricuspid VIVID registry, reported on the outcomes
and freedom from reintervention
echocardiographic of 152 patients.13 In this cohort, the age of the failing surgical bio-
of only 53% at 15 years after sur-
prostheses was #5 years in as many as 30% of the patients, high-
TR = Tricuspid regurgitation gical valve replacement.14,15,31
lighting the accelerated degeneration observed in tricuspid
TS = Tricuspid stenosis bioprostheses. Overall, the study confirmed high procedural success
(99%) as well as excellent safety, with only one procedural death
TTE = Transthoracic
echocardiography EMERGENCE OF and no acute conversion to open-heart surgery despite two valve em-
TRANSCATHETER bolizations that were managed percutaneously. Significant improve-
TV = Tricuspid valve ment of invasive transvalvular gradient and severity of TR were
TREATMENT
ViV = Valve-in-valve observed regardless of the type of valve implanted, which translated
ALTERNATIVES
into sustained functional improvement in 76% of patients. Survival
VIVID = Valve-in-Valve free from reintervention was 85% at 1 year. Valve thrombosis was sus-
International Database Reoperation for valve degenera-
pected in 4 patients (3%), and 4 additional patients (3%) met the
tion is associated with mortality
VTI = Velocity-time integral criteria for valve endocarditis. All-cause mortality was low, with a re-
ranging from 17% to 37%,14-17
ported incidence of 3% at 30 days and a total of 22 deaths (15%)
and isolated reoperative TV
during a median follow-up period of 13 months.
replacement is one of the highest risk operations classified in the
Society of Thoracic Surgeons registry. Novel transcatheter therapies
are emerging for the treatment of TR,32 including transcatheter TRANSTHORACIC ECHOCARDIOGRAPHIC ASSESSMENT
tricuspid ViV implantation for patients with tricuspid bioprosthetic OF DEGENERATIVE TV BIOPROSTHESIS
valve stenosis and/or transvalvular regurgitation deemed too high
risk or unsuitable for reoperation. Notwithstanding, younger patients Preprocedural transthoracic echocardiography (TTE) is an excellent
with Ebstein’s anomaly requiring multiple valve replacements first-line diagnostic tool in the assessment of tricuspid bioprosthetic valve
because of somatic growth or bioprosthesis degeneration may also function, as the anterior location of the TV permits favorable echocar-
benefit from transcatheter intervention as a mechanism to extend diographic visualization and evaluation of prosthetic valve function.
the duration between repeat valve operations.33,34 The primary goal of TTE is to evaluate the severity, mechanism, and
Tricuspid ViV transcatheter treatment of degenerated tricuspid bio- anatomic substrate for prosthetic valve dysfunction, which may involve
prostheses was first successfully performed using the Melody valve tricuspid stenosis (TS), TR, or a combination of TS and TR. Common
(Medtronic, Minneapolis, MN) in 2010 through a jugular venous route causes of tricuspid bioprosthetic valve dysfunction include leaflet degen-
in a patient with previous TV replacement (27-mm Medtronic Mosaic eration, leaflet thrombosis, endocarditis-related leaflet damage, and
valve) 8 years after treatment for TVendocarditis.3 Evolution of the ac- pannus formation. Paravalvular regurgitation is usually related to endo-
cess routes subsequently followed: in 2010, a 26-mm Edwards carditis or surgical suture tear. TTE should determine the presence or
SAPIEN transcatheter heart valve (Edwards Lifesciences, Irvine, CA) absence of thrombus, infective endocarditis, or paravalvular leak, as
was implanted for the first time into a Medtronic Mosaic 27-mm bio- these are exclusion criteria for transcatheter tricuspid ViV. The specific
prosthesis through a right atriotomy (off pump),4 and a fully percuta- role of TTE in determining the size of surgical and transcatheter valve
neous procedure using the jugular venous approach was described devices is limited; operative notes, multislice computed tomography
shortly later using a 23-mm SAPIEN valve5 in 2011. Upon commercial (MSCT), TEE imaging, and fluoroscopy are more reliable modalities
availability of the steerable RetroFlex delivery system, transfemoral for selecting transcatheter device size (see below).
venous implantation of a SAPIEN XT valve became technically Comprehensive assessment of a patient with tricuspid bioprosthesis
possible, paving the way for a simplified and more convenient degeneration should include 2D and 3D imaging, as well as color flow,
tricuspid ViV procedure.6 Subsequently, the safety, feasibility, and ef- continuous-wave (CW), and pulsed-wave Doppler imaging. Multiple
ficacy of the tricuspid bioprosthesis ViV procedure has been windows should be used: parasternal RV inflow and short-axis, apical
Journal of the American Society of Echocardiography Praz et al 493
Volume 31 Number 4

Figure 1 Transthoracic imaging of tricuspid bioprosthesis degeneration with TS. A 31-mm Medtronic Mosaic tricuspid bioprosthesis
with leaflet thickening on 2D imaging (A) (Video 1), a dilated, noncollapsing IVC (B) (Video 2), turbulent diastolic forward flow (C) (Video
3), and increased (14 mm Hg) mean pressure gradient (D). PG, Pressure gradient; RA, right atrium; Vmax, mean maximum velocity;
Vmean, mean velocity.

four-chamber, and subcostal views. On the occasion that acoustic Tricuspid Bioprosthetic Valve Stenosis
shadowing limits evaluation in conventional views, alternative trans- A combination of quantitative and qualitative assessments is used to
thoracic echocardiographic windows such as short-axis subcostal or determine the presence and severity of prosthetic TS (Table 1,
low parasternal may prove as useful as TEE imaging. In patients with Figure 1). Two-dimensional imaging of the TV bioprosthesis includes
adequate 2D images, simultaneous biplane imaging in orthogonal evaluation of valve seating, leaflet appearance, and leaflet mobility.
planes with complementary 3D images allows comprehensive evalu- The appearance of leaflet thickening, calcification, and/or hypomobil-
ation of the prosthetic TV and its leaflets. However, low temporal and ity (Video 1, available at www.onlinejase.com), with right atrial
spatial resolutions36 are recognized limitations of 3D TTE of the TV. As enlargement and a dilated noncollapsing inferior vena cava (IVC;
with all prosthetic valves, the valve size of the tricuspid bioprosthesis Video 2, available at www.onlinejase.com), may suggest the presence
should be recorded, if known, in all cases. of TV stenosis. Normal color flow Doppler signal across the tricuspid
494 Praz et al Journal of the American Society of Echocardiography
April 2018

Table 2 Echocardiographic and Doppler parameters used in grading severity of prosthetic TV regurgitation

Parameter Mild Moderate Severe

Valve structure Usually normal Abnormal or valve Abnormal or valve

dehiscence dehiscence
Jet area by color <5 5–10 >10
Doppler, central jets
only (cm2)
Vena contracta width Not defined Not defined, but <0.7 >0.7
(cm)*
Jet density/contour by Incomplete or faint, Dense, variable contour Dense with early
CW Doppler parabolic peaking
Doppler systolic Normal or blunted Blunted Holosystolic reversal
hepatic flow
Right atrium, right Normal† Dilated Markedly dilated
ventricle, IVC
*For a valvular TR jet, extrapolated from native TR; unknown cutoffs for paravalvular TR.
†
If no other reason for dilatation. Reprinted from Zoghbi WA et al.40

bioprosthesis is typically laminar in appearance; turbulent and/or nar- regurgitation is no more than mild), the RV outflow tract stroke vol-
rowed or eccentric color Doppler inflow suggests the presence of ume may be used instead of LVOT stroke volume. If greater than
prosthetic TV stenosis (Video 3, available at www.onlinejase.com). mild TR is present, the continuity equation should not be used to
CW Doppler across the prosthetic valve inflow measures transvalvu- assess EOA. According to American Society of Echocardiography
lar peak velocity and mean gradient and has been validated against guidelines, peak TV velocity > 1.7 m/sec, mean
catheter-derived data.37,38 To capture maximal transvalvular gradient > 6 mm Hg, and/or PHT > 230 msec suggest prosthetic
gradients, CW Doppler interrogation of prosthetic valve inflow TV obstruction40 (Table 1). In a large, more recent series of normal
should be performed from multiple echocardiographic windows, TV bioprostheses evaluated early after implantation, alternative
although the typical window to obtain the highest Doppler velocity thresholds for abnormal Doppler flow parameters have been pro-
is the apical four-chamber view, in which the flow direction is parallel posed: transvalvular peak velocity > 2.1 m/sec, mean
to the transducer beam. The baseline should be shifted and the scale gradient > 8.8 mm Hg, and PHT > 193 msec.41
adjusted accordingly to allow optimal visualization and tracing of the
spectral Doppler signal. CW Doppler measurements may vary with
both heart rate and respiration, and a minimum of five cardiac cycles Tricuspid Bioprosthetic Valve Regurgitation
should be recorded and averaged to account for respirophasic varia- As with TS, a combination of quantitative and qualitative assessments
tion of right-sided flow, even when the patient is in sinus rhythm.39,40 is used to determine the presence and severity of prosthetic TR
The average heart rate should also be noted because it can (Table 2). TR may be either transvalvular or paravalvular in origin,
substantially affect the inflow gradient: diastole (time for atrial and careful 2D assessment of the prosthetic TV from all available win-
emptying) shortens with increasing heart rate, and a shorter diastole dows is necessary for complete evaluation. In the presence of clini-
will of necessity result in a higher mean gradient. cally significant paravalvular regurgitation, percutaneous closure can
Doppler parameters such as peak E velocity, peak A velocity (in si- be considered as a corrective strategy,42 whereas the extreme situa-
nus rhythm), and velocity-time integral (VTI) across the valve can be tion of ‘‘valve rocking,’’ suggestive of valve dehiscence, represents a
measured to corroborate qualitative findings. Measurement of pres- contraindication to a ViV procedure. However, quantitation of para-
sure half-time (PHT) and calculation of prosthetic valve effective valvular leaks is not established for TV prostheses. One might catego-
orifice area (EOA) are additional parameters that can quantify pros- rize severity by inferring from aortic valve literature and estimating the
thetic TV stenosis. The PHT is the time required for the maximal pres- proportion of the annular circumference occupied by the leak,39 but
sure gradient to decrease by half.39 Transvalvular gradient may be this method has not been validated for TV prostheses. If transvalvular
increased because of obstruction or regurgitation. In the context of TR is present, transthoracic echocardiographic assessment should
increased transvalvular mean gradient, the PHT is a useful tool to include qualitative assessment of TV leaflets (prolapse, flail), failure
differentiate between the two, as a prolonged PHT is suggestive of of leaflet coaptation (Video 4, available at www.onlinejase.com),
obstruction. Note that the PHT should not be used to calculate the and quantitative assessment of the regurgitant volume. Severe TR is
EOA of TV prostheses but rather serve as a stand-alone measurement, usually associated with right atrial and RV dilatation, diastolic ventric-
because PHT-derived EOA calculation overestimates TV area ular septal flattening, IVC dilatation, and hepatic vein systolic flow
compared with continuity equation–derived methods.41 The conti- reversal (Figure 2). On color Doppler imaging, a large flow conver-
nuity equation is the preferred method for calculation of prosthetic gence (Video 5, available at www.onlinejase.com) and increased
TV valve EOA. This is typically performed by calculating the stroke vena contracta width (>0.7 cm), effective regurgitant orifice
volume across the left ventricular outflow tract (LVOT) and dividing area $ 40 mm2, and regurgitant volume $ 45 mL/beat all suggest se-
it by the CW Doppler–derived prosthetic TV VTI. This calculation vere TR, as does a dense CW Doppler tracing with a triangular, early-
is accurate in the absence of significant aortic or TR. In the context peaking velocity, and increased transvalvular Doppler measurements
of greater than mild aortic regurgitation (and if pulmonic valve (peak velocity and mean gradient).39,40 A VTI ratio between the TV
Journal of the American Society of Echocardiography Praz et al 495
Volume 31 Number 4

Figure 2 Transthoracic imaging of tricuspid bioprosthesis degeneration with TR. A 33-mm Medtronic Mosaic tricuspid bioprosthesis
with tricuspid leaflet prolapse (A) (Video 4), large forward flow convergence with eccentric TR on color Doppler imaging (B) (Video 5),
dense CW Doppler tracing with a triangular, early-peaking velocity (C), and systolic flow reversal in the hepatic vein (D). PG, Pressure
gradient; Vmax, maximum velocity.

prosthesis (VTIPrTV; CW Doppler derived) and the LVOT (VTILVOT; the American Society of Echocardiography advocates the use of mul-
pulsed-wave Doppler derived) of >3.3 in the context of increased tiple comprehensive TEE windows from multiple depths and plane
transvalvular gradient and normal PHT may help confirm the pres- angles.43,44 The midesophageal four-chamber view with simulta-
ence of significant TR.40 Three-dimensional color Doppler imaging neous biplane imaging permits visualization of the septal and anterior
may be also helpful, but its role in quantifying the regurgitant volume TV leaflets (Figure 3A), where the anterior leaflet is usually adjacent to
has not been extensively evaluated. the aorta.45 However, in the midesophageal windows, the TV is in the
far field and may be subject to beam widening and attenuation;
further insertion of the TEE probe to the distal esophageal, shallow
PROCEDURAL IMAGE GUIDANCE WITH TEE IMAGING transgastric, and deep transgastric views approximates the TEE probe
and the TV, bringing the TV into the near field and optimizing win-
Imaging the TV dows of the TV. At the distal esophageal view, the absence of left heart
The tricuspid annular plane is anterior, almost vertical, and orientated structures from the image allows comprehensive 3D assessment of
approximately 45 from the sagittal plane. To fully visualize the TV, TV function (Figure 3B); in the transgastric views, multiplane imaging
496 Praz et al Journal of the American Society of Echocardiography
April 2018

Figure 3 Transesophageal multilevel imaging of the TV. (A) Midesophageal biplane imaging, showing the anterior TV leaflet (in blue,
typically adjacent to the aorta) and septal leaflet (in yellow). (B) Low-esophageal biplane imaging, at the level of the coronary sinus
(asterisk), visualizing the posterior (in green) and anterior TV leaflets. (C) Transgastric biplane imaging: the short-axis view provides en
face simultaneous visualization of all three TV leaflets. (D) All the leaflet coaptation points can be imaged using simultaneous multi-
plane imaging mode in deep-gastric biplane view.

(or rotating the probe 60 –90 ) produces simultaneous en face visu- of the guidance catheter in the right atrium can thereafter be desig-
alization of all three TV leaflets (Figure 3C) and is an ideal view for nated for clear orientation46 as
differentiating transvalvular TR from paravalvular TR and for diag-
 toward the aortic valve (‘‘aortic direction’’),
nosing thrombus or vegetations on the leaflets; in the deep transgas-
 toward the posterior leaflet (‘‘posterior’’ direction), or
tric view, rightward anterior flexion45 (Figure 3D) permits optimal TV
 toward the septal leaflet (‘‘septal’’ direction).
color flow and spectral Doppler evaluation of TR jets. It is important
to rotate through multiple planes at each TEE level and use simulta-
neous orthogonal imaging to evaluate the TV comprehensively, to
help with identifying leaflets, and to appreciate adjacent anatomy. Selection of Transcatheter Valve Size
In most tricuspid ViV cases, transcatheter valve sizing is based on the
known size of the preexisting bioprosthesis. Because of the presence
Anatomy, Orientation, and Nomenclature of the leaflets mounted inside the valve, the true internal diameter
Standardized intraprocedural imaging RT 3D TEE TV orientation and (which determines prosthesis anchoring) is typically 1 to 2 mm
nomenclature accurately guide the interventionalist to the target smaller than the diameter of the surgical valve size reported by the
segment of the TV valve. This is essential in transcatheter TV repair manufacturer. Because there are no dedicated surgical bioprostheses
for native TV disease18-21 but also important in tricuspid ViV for the tricuspid position, a useful guide for sizing is the mitral ViV
procedures. In a standardized RT 3D TEE study of a failing TV application.47 However, even when the surgical valve size is known,
bioprosthesis, the TV 3D volume image should be rotated so that valve selection is not standardized, and the labeled dimensions
the TV leaflets are visualized en face from the atrial side, with the (including external and internal diameter) may vary according to
interatrial septum placed inferiorly and the aortic valve to the left the manufacturer. Preprocedural planning should therefore include
on the screen (Figure 4), so that the coronary sinus enters the right MSCT and TEE imaging in all patients.48 Balloon sizing using fluoros-
atrium close to the commissure between the septal and posterior leaf- copy can be considered at the beginning of the tricuspid ViV proced-
lets.36 In this 3D surgical view, the leaflet opposite the aortic valve is ure but is used much less commonly than in aortic valve disease.49
the posterior leaflet, the leaflet adjacent to the aortic valve is the ante- The selected transcatheter device should have an external diameter
rior leaflet, and the remaining leaflet is the septal leaflet. Movements that best matches the true internal diameter of the failing surgical
Journal of the American Society of Echocardiography Praz et al 497
Volume 31 Number 4

Figure 4 Standardized RT 3D transesophageal image of a normal TV (A) with TV leaflets visualized en face from the atrial side
(interatrial septum inferiorly, aortic valve left on the screen). The TV leaflet opposite the aortic valve is the posterior leaflet, the
leaflet adjacent to the aortic valve is the anterior leaflet, and the remaining leaflet is the septal leaflet. Standardized (RT 3D) image
of a TV bioprosthesis (B) and mitral bioprosthesis. Standardized (RT 3D) of a TV incomplete annuloplasty ring (C).

bioprosthesis to ensure secure anchoring of the transcatheter de- patients with recently implanted transvalvular leads, because of the
vice.50 Valve sizing should consider the amount of leaflet thickening, increased risk for lead dislodgement. Patients with implantable
calcification and pannus formation that may further reduce the pros- defibrillators may also be at risk for relevant paravalvular
thesis internal diameter.51 Measurement of the TV bioprosthesis inter- regurgitation because of the larger dimensions of the lead; in this
nal diameter is best performed by RT 3D imaging in multiple views, situation, use of the SAPIEN 3 may be advantageous, as the outer
and oversizing by approximately 10% will ensure secure anchoring cuff may promote improved sealing. Although not mandatory,
of the implant within the sewing ring and minimize intervalvular rapid ventricular pacing during the ViV procedure can be facilitated
regurgitation. Undersizing risks device migration, while excessive through placement of a transarterial temporary pacing lead either in
oversizing may distort the transcatheter valve leaflets and affect he- the left ventricle or in the coronary sinus, especially in patients with
modynamics and durability. The final decision regarding TV ViV de- high pacemaker dependency. Alternatively, guidewire pacing may
vice sizing therefore usually involves an integrated approach, taking be attempted. In all cases, the position of the pacing leads should
into account the manufacturer’s guidance as well as the mean diam- be confirmed with periprocedural TEE imaging.
eters determined by MSCT and RT 3D TEE imaging.

Access Route
Management of Pacing Wires Although transjugular access offers the most direct approach to the
A transvalvular pacemaker or cardioverter defibrillator lead is present tricuspid annulus, advances in catheter steerability enables transfe-
in about 18% of patients with surgical TVs52 and is, as a consequence, moral valve delivery in almost two thirds of patients.13 When transfe-
not infrequently encountered in tricuspid ViV candidates. Limited moral access is being considered, the IVC–right atrium junction and
data suggest that jailing of the lead between the stent of the surgical angulation into the right atrium should be assessed in the mid and
valve and the frame of the transcatheter bioprosthesis might be deep esophageal 2D TEE windows, as access to a failing TV bio-
safe, with low risk for lead dysfunction or relevant paravalvular prosthesis may be complicated by acute angulation from the IVC
leak.53,54 However, tricuspid ViV should not be performed in and the RV annulus.
498 Praz et al Journal of the American Society of Echocardiography
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Figure 5 Tricuspid ViV in a patient with rheumatic heart disease. (A) Predilation of a stenotic 33-mm Carpentier-Edwards (CE) Peri-
mount pericardial valve. The permanent extravalvular pacemaker lead does not interfere with the ViV procedure. (B) Placement of a
29-mm Edwards SAPIEN 3 valve and slow deployment under TEE control. (C) Position of the transcatheter valve overlapping the sur-
gical bioprosthesis. During deployment, self-centering occurred. (D) Following concomitant TAVR for treatment of coexisting aortic
stenosis, the intervention finally results in the replacement of three valves (asterisk, 23-mm Edwards SAPIEN 3 bioprosthesis in aortic
position; double asterisk, 29-mm Edwards SAPIEN 3 valve in 33-mm CE surgical bioprosthesis; arrow, mechanical mitral valve with
open leaflets). PA, Pulmonary artery.

Advancement of the Transcatheter Valve System (stented bovine jugular vein graft) and the Edwards SAPIEN device13
Once tricuspid bioprosthesis degeneration has been confirmed on RT (pericardial leaflets). The Melody valve has very thin, pliable leaflets
3D TEE imaging (Videos 6–8, available at www.onlinejase.com), the and maybe less prone to thrombose than surgically implanted porcine
next stage is advancement of the transcatheter valve system. prosthesis or pericardial SAPIEN devices. Although the Melody valve
Regardless of access route, a stiff wire (such as an Amplatz Extra can be expanded over its nominal diameter (22 mm) when mounted
Stiff [Cook Medical, Bloomington, IN] with a small distal loop or a on a 24- or even a 25-mm balloon, the Edwards SAPIEN XT or
Confida [Medtronic] with a preshaped loop) is positioned either in SAPIEN 3 valve may be more adapted to the large size of surgical
the distal pulmonary artery or RV apex under RT 3D guidance, tricuspid bioprostheses and is the preferred system for this particular
ensuring sufficient stability for traversing of the transcatheter heart indication. In bioprostheses exceeding a labeled diameter of 30 mm,
valve from the right atrium into the right ventricle (Figure 5). Two- prestenting of the surgical valve with a metallic stent (e.g., CP Stent)
dimensional (Figure 6E) and RT 3D (Figure 6F, Video 9, available at has been proposed.6
www.onlinejase.com) imaging should be used to monitor wire deliv- Maneuvering the transcatheter valve into position across the bio-
ery and catheter positioning across the degenerative bioprosthesis: prosthesis often represents the most challenging aspect of the ViV
increasing the gain in the deep esophageal view of the TV will aid intervention. The failing TV bioprosthesis may have fluoroscopic
visualization of the TV leaflets, while decreasing the gain will aid visu- landmarks and anchoring zones for transcatheter valve deployment,
alizing the wire and catheter. Imaging the wire and catheter from the so this stage of the procedure can be performed under fluoroscopic
right ventricle (i.e., underneath the RV annulus) allows assessment of guidance. However, fluoroscopic markers are not always present,55
the correct trajectory and limits the possibility of RV puncture. and continuous 2D and RT 3D TEE imaging is then mandatory in
Biplane imaging in the transgastric views readily confirms the depth careful alignment and positioning of the transcatheter device
and position of the wire and delivery catheter, particularly if the trajec- (Figure 6G, Video 10, available at www.onlinejase.com) using the
tory of the wire is in a different plane to the annulus. The position of nomenclature described above. Significant back-and-forth or
the wire should be visible in the right atrium using RT 3D imaging. If ‘‘push-pull’’ manipulation of the stiff wire while flexing the delivery
the position is not acceptable, the wire should be removed. Crossing system may be necessary. The delivery system should be oriented
the TV bioprosthesis may be difficult in cases of TV leaflet calcification 90 to 180 opposite the normal orientation to facilitate flexion
or pannus, and predilation has been reported in about 50% of these in the appropriate angulation (Figure 5). Orientation of the
instances.13 In contrast, predilatation of the bioprosthesis should be C-arm, typically into a right anterior oblique projection, perpendic-
avoided in cases of obvious severe TR to prevent risk for leaflet ular to the surgical valve stent, offers considerable navigation help
rupture or embolization. and may ease valve crossing. Advances in echocardiographic tech-
In contrast to the transcatheter Forma Repair System (Edwards nology with the new EchoNavigator system (Philips Healthcare,
Lifesciences), which is designed to provide a surface for native leaflet Best, the Netherlands) enable RT merging of echocardiographic
coaptation to reduce TR by occupying the regurgitant orifice area,18 and fluoroscopic images on the same display and may contribute
tricuspid ViV device type choice is usually between the Melody valve to procedural success.50
Journal of the American Society of Echocardiography Praz et al 499
Volume 31 Number 4

Figure 6 Intraprocedural transesophageal imaging. Severe tricuspid bioprosthesis degeneration should be demonstrated on RT 3D TEE
imaging (flail leaflets) (A) (Video 6) and severe TR confirmed on fluoroscopy (B) (Video 7), color Doppler (C) (Video 8), and CW Doppler (D).
Two-dimensional (E) and RT 3D TEE (F) imaging (Video 9) are used to monitor wire and delivery catheter positioning across the failed TV
bioprosthesis and to assist in alignment and positioning of the transcatheter device (G) (Video 10). After ViV deployment, the position and
circularity of the transcatheter device should be assessed, and symmetric leaflet mobility visualized (H) (Video 11). Tricuspid inflow gra-
dients should be measured to exclude significant TS (I), and the presence or absence of transvalvular and paravalvular TR should be
sought (J) (Video 12). PG, Pressure gradient; RA, right atrium.
500 Praz et al Journal of the American Society of Echocardiography
April 2018

Figure 7 Paravalvular leak (PVL) after tricuspid ViV implantation. Color Doppler may demonstrate a PVL between the newly implanted
transcatheter device and the failed tricuspid bioprosthesis (Video 13).

Figure 8 TS after tricuspid ViV implantation. Six weeks after tricuspid ViV, the transcatheter device leaflets had become thickened
with reduced mobility (A) (Video 14, available at www.onlinejase.com). Color Doppler (Video 15, available at www.onlinejase.com)
and CW Doppler (B) confirmed TS (mean gradient, 4 mm Hg). The patient had been noncompliant with oral anticoagulant therapy.
PG, Pressure gradient.

Immediate Postimplantation Evaluation of ViV Function TV inflow gradients should be assessed to exclude significant TS
As with all ViV procedures, potential complications include device (Figure 6I), and the presence or absence of transvalvular and para-
malpositioning, migration, and embolization; all should be valvular TR should be sought (Figure 6J, Video 12, available at
excluded with periprocedural TEE imaging. A rigid bioprosthesis www.onlinejase.com). Because the implanted valve is usually large
or a degenerative bioprosthesis with bulky leaflets may create a (>29 mm13), post-ViV patient-prosthesis mismatch is usually
noncircular landing zone, resulting in underexpansion of the trans- avoided. The right coronary artery and the coronary sinus run
catheter device: the position and circularity of the transcatheter close to the atrioventricular groove, and Although both are likely
device should therefore be assessed, and symmetric leaflet to be protected by the rigid frame of the failing bioprosthesis,
mobility should be visualized (Figure 6H, Video 11, available at there may be distortion or rupture into the right coronary artery,
www.onlinejase.com). Postdilation is more frequent after place- with subsequent RV wall motion abnormalities and cardiac tam-
ment of a Melody valve (40% vs 26% with the SAPIEN valve).13 ponade.
Journal of the American Society of Echocardiography Praz et al 501
Volume 31 Number 4

Figure 10 Distribution of mean gradients across TV before and

after transcatheter ViV implantation. Percentage of patients in
the tricuspid VIVID registry with tricuspid inflow gradient as
measured by CW Doppler before, immediately after, and at
most recent follow-up of transcatheter valve implantation. Re-
printed with permission from McElhinney et al.13 TVIV, Tricuspid
valve-in-valve; FU, follow-up.

transcatheter valve should be interrogated by color flow Doppler

to exclude paravalvular leak. Small paravalvular jets are common
(Figure 7, Video 13, available at www.onlinejase.com) and often
resolve over time with endothelialization,48 but larger paravalvular
leaks may require repeat balloon dilation, percutaneous plug closure
if anatomically suitable, or surgical repair. American College of
Cardiology and American Heart Association guidelines suggest
that percutaneous closure of paravalvular leaks is reasonable in
symptomatic patients with New York Heart Association class III or
IV heart failure who are high-risk surgical candidates (Class IIa,
Figure 9 TR after tricuspid ViV implantation. On routine 6-month Level of Evidence [LOE]: B).56 Centers of expertise in percutaneous
follow-up, ongoing right atrial dilatation was present (A), and closures have reported success rates of 80% to 85%. Although right-
there was no paravalvular leak (B), no significant TS, and mild sided pacemaker and defibrillator leads can theoretically interact
transvalvular TR (C). PG, Pressure gradient; RA, right atrium; with the valve structure and cause device instability or paravalvular
Vmax, maximum velocity. leak, this has not been reported in the literature.54
Tricuspid ViV leaflet motion should be assessed by 2D TTE for
leaflet excursion and restricted motion (Videos 14 and 15, available
POSTPROCEDURAL ECHOCARDIOGRAPHIC ASSESSMENT at www.onlinejase.com). The inflow gradient across the TV device
OF TV FUNCTION AFTER VIV IMPLANTATION should be interrogated by CW Doppler (Figure 8B): as described
above, a mean transvalvular gradient of <5 mm Hg is considered
Transthoracic echocardiographic evaluation of tricuspid ViV function normal for native57 and prosthetic40 TVs, although a study of nor-
is not yet validated in clinical studies. Guidance is derived from mally functioning surgically implanted heterograft bioprostheses pre-
American Society of Echocardiography guidelines for evaluating a viously recorded mean gradients up to 5.8 mm Hg.58 The tricuspid
surgically implanted prosthetic TV,39 expert recommendations VIVID registry reported mean gradients <5 mm Hg following
derived from native valve evaluation with minor modifications, case Melody and SAPIEN tricuspid ViV procedures,13 though patients
report experience, and the tricuspid VIVID registry.3-13 with smaller surgical valves (irrespective of valve type) tend to have
higher postimplantation gradients (<10 mm Hg, empirically set as
the threshold for TS for the registry population). It is important to re-
Immediate Postimplantation Transthoracic emphasize that diastolic gradients across atrioventricular valves are
Echocardiographic Assessment heart rate dependent; the higher the heart rate, the shorter the time
TTE within 24 hours postprocedure is recommended to reassess for diastole and the higher the pressure gradient. Note should there-
both valve function and the pericardial space for effusion. fore be taken of the heart rate at the time of measuring ViV tricuspid
Comprehensive evaluation of the valve apparatus begins with assess- gradients as a reference for serial follow-up measurements.
ing the valve position and stability, though fortunately valve emboli- The TV device should also be interrogated with color flow
zation is rare,13 usually occurs during the implantation process, and is Doppler to assess for the presence and severity of transvalvular
recognized intraprocedurally. The space between the surgical and TR after tricuspid ViV implantation (Figure 9). One case report
502 Praz et al Journal of the American Society of Echocardiography
April 2018

Figure 11 Summary: use of echocardiography in transcatheter tricuspid ViV intervention for degenerative TV disease.

identified three patients with Ebstein’s anomaly and early valve fail- (graded as none or mild in 94% of patients). Long-term bioprosthetic
ure within 2 weeks of tricuspid ViV implantation despite excellent leaflet failure in the tricuspid position, similar to other positions, is
immediate postimplantation results with minimal TR.59 The au- most likely due to leaflet degeneration and calcification, followed
thors hypothesized that abnormal right atrial mechanics may pre- by endocarditis, thrombus, or pannus formation.60 A meta-analysis
clude appropriate leaflet coaptation and cause accelerated leaflet of outcomes in surgical bioprosthetic TVs estimated a deterioration
degeneration. Close transthoracic echocardiographic follow-up is rate of 1.7% of patients per year.61 Postimplantation dysfunction is
therefore be warranted in specific classes of patients and those likely to depend on RV size and function, thrombus and possible
demonstrating clinical change. infection, and structural degeneration over time. Initial comprehen-
sive TTE is recommended at 6 weeks to 3 months after surgical or
transcatheter prosthetic valve implantation to assess valve function
Tricuspid ViV Follow-up Imaging and to establish the patient’s new baseline for future comparison,
Because of still limited experience of tricuspid VIV, normal ranges for ideally at a point of hemodynamic stability in an asymptomatic state
TV device function after tricuspid-ViV intervention have not yet been (Class I, LOE: B).56 Repeat TTE is warranted with change in clinical
established, though the tricuspid VIVID registry has proved instruc- symptoms or suspected prosthetic valve dysfunction (Class I, LOE:
tive in providing large retrospective case data.13 For the majority of pa- C), and annual TTE is reasonable in patients with a bioprosthetic valve
tients, mean TV inflow gradient (median, 5 mm Hg) did not change after the first 10 years, even in the absence of a change in clinical status
significantly from the immediate postimplantation TTE to a median (Class IIa, LOE: C).56 Early transthoracic echocardiographic diagnosis
of 13.3 months (Figure 10), and the degree of TR remained stable in the asymptomatic patient may identify severe TR or progressive RV
Journal of the American Society of Echocardiography Praz et al 503
Volume 31 Number 4

dilatation that warrants intervention or asymptomatic TS that neces- 4. Hon JK, Cheung A, Ye J, Carere RG, Munt B, Josan K, et al. Transatrial
sitates more frequent monitoring for symptoms and serial imaging. transcatheter tricuspid valve-in-valve implantation of balloon expandable
The low-flow right-sided valves are at higher risk for valvular bioprosthesis. Ann Thorac Surg 2010;90:1696-7.
thrombosis, usually manifest by increasing inflow gradients, though 5. Van Garsse LA, Ter Bekke RM, van Ommen VG. Percutaneous transcath-
eter valve-in-valve implantation in stenosed tricuspid valve bioprosthesis.
thrombosis can also be accompanied by TR due to restricted leaflet
Circulation 2011;123:e219-21.
motion and incomplete closure.62-64 Dedicated imaging by
6. Kenny D, Hijazi ZM, Walsh KP. Transcatheter tricuspid valve replacement
transesophageal echocardiography or MSCT may be required for with the Edwards SAPIEN valve. Catheter Cardiovasc Interv 2011;78:
comprehensive assessment of thrombus versus pannus in the 267-70.
presence of elevated gradients (Class I, LOE: C).56 On the basis of 7. Jux C, Akintuerk H, Schranz D. Two Melodies in concert: transcatheter
transcatheter aortic valve experience, most patients are placed on double-valve replacement. Catheter Cardiovasc Interv 2012;80:997-1001.
dual-antiplatelet therapy for 6 months after implantation to minimize 8. Laule M, Stangl V, Sanad W, Lembcke A, Baumann G, Stangl K. Percuta-
the risk for thrombosis. Only four patients in the tricuspid VIVID reg- neous transfemoral management of severe secondary tricuspid regurgita-
istry with elevated gradients after tricuspid ViV were found to have tion with Edwards SAPIEN XT bioprosthesis: first in-man experience. J
thrombus or leaflet immobility while on aspirin alone2 or aspirin Am Coll Cardiol 2013;61:1929-31.
9. Lilly SM, Rome J, Anwaruddin S, Shreenivas S, Desai N, Silvestry FE, et al.
with warfarin.2,13 Therapeutic oral anticoagulation or fibrinolysis
How should I treat prosthetic tricuspid stenosis in an extreme surgical risk
may be considered if thrombus is identified on a right-sided valve
patient? Eurointervention 2013;9:407-9.
(Class IIa, LOE: B).55 Infective endocarditis has been reported after 10. Mazzitelli D, Bleiziffer S, Noebauer C, Ruge H, r P, Opitz A, et al. Transat-
tricuspid ViV: four patients in the tricuspid VIVID registry (all rial antegrade approach for double mitral and tricuspid ‘‘valve-in-ring’’ im-
receiving Melody valves) were diagnosed with endocarditis with plantation. Ann Thorac Surg 2013;95:e25-7.
Enterococcal and Candida species, the latter requiring surgical replace- 11. Mick SL, Kapadia S, Tuzcu M, Svensson LG. Transcatheter valve-in-valve
ment for sepsis and multiple pulmonary emboli, the others treated tricuspid valve replacement via internal jugular and femoral approaches.
medically without significant valvular dysfunction.13 New paravalvu- J Thorac Cardiovasc Surg 2014;147:e64-5.
lar leak identified by TTE in the follow-up period should raise concern 12. Mortazavi A, Reul RM, Cannizzaro L, Dougherty KG. Transvenous trans-
for valve dehiscence and instigate workup for infective endocarditis catheter valve-in-valve implantation after bioprosthetic tricuspid valve fail-
ure. Tex Heart Inst J 2014;41:507-10.
with blood cultures and possible TEE imaging to assess for vegetation,
13. McElhinney DB, Cabalka AK, Aboulhosn JA, Eicken A, Boudjemline Y,
valve destruction, perivalvular abscess, and fistula formation.
Schubert S, et al. Valve-in-Valve International Database (VIVID) registry.
Transcatheter tricuspid valve-in-valve implantation for the treatment of
dysfunctional surgical bioprosthetic valves: an international, multicenter
CONCLUSIONS registry study. Circulation 2016;133:1582-93.
14. Guenther T, Noebauer C, Mazzitelli D, Busch R, Tassani-Prell P, Lange R.
Tricuspid ViV interventions for failing tricuspid bioprostheses may Tricuspid valve surgery: a thirty-year assessment of early and late outcome.
represent an attractive alternative to redo open heart surgery in pa- Eur J Cardiothorac Surg 2008;34:402-9.
tients deemed at high risk for repeat surgical intervention. Published 15. quis-Gravel G, Bouchard D, Perrault LP, Page P, Jeanmart H, Demers P,
data show high safety and good efficacy of the tricuspid ViV implan- et al. Retrospective cohort analysis of 926 tricuspid valve surgeries: clinical
tation procedure from both a hemodynamic and a functional point of and hemodynamic outcomes with propensity score analysis. Am Heart J
2012;163:851-8.
view, though assessment of durability and long-term follow-up is
16. Bernal JM, Morales D, Revuelta C, Llorca J, Gutierrez-Morlote J,
necessary. Successful transcatheter tricuspid ViV implantation re-
Revuelta JM. Reoperations after tricuspid valve repair. J Thorac Cardiovasc
quires comprehensive understanding of 2D and RT 3D transthoracic Surg 2005;130:498-503.
and TEE images to detect early bioprosthetic failure, to guide peripro- 17. McCarthy PM, Bhudia SK, Rajeswaran J, Hoercher KJ, Lytle BW,
cedural intervention, and to assess residual TV disease (Figure 11). Cosgrove DM, et al. Tricuspid valve repair: durability and risk factors for
failure. J Thorac Cardiovasc Surg 2004;127:674-85.
18. Campelo-Parada F, Perlman G, Philippon F, Ye J, Thompson C, B
edard E,
SUPPLEMENTARY DATA et al. First-in-man experience of a novel transcatheter repair system for
treating severe tricuspid regurgitation. J Am Coll Cardiol 2015;66:
2475-83.
Supplementary data related to this article can be found at http://dx.
19. Schofer J, Bijuklic K, Tiburtius C, Hansen L, Groothuis A, Hahn RT. First-in-
doi.org/10.1016/j.echo.2017.06.014. human transcatheter tricuspid valve repair in a patient with severely regur-
gitant tricuspid valve. J Am Coll Cardiol 2015;65:1190-5.
20. Hammerstingl C, Schueler R, Malasa M, Werner N, Nickenig G. Transcath-
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