Shinshu Med J, 67⑸：289～292, 2019

Percutaneous Transcatheter Balloon Valvuloplasty ofa Stenosed Bioprosthetic Tricuspid ValveToshinori Komatsu1）＊, Yusuke Miyashita1）, Masafumi Kanai1）
Kunihiko Shimizu1）, Naoyuki Abe1）, Tatsuya Usui1）, Izumi Miyazawa1）
Tamaki Takano2）, Nobuyuki Totsuka1） and Jiro Yoshioka1）
1） Department of Cardiology, Nagano Red Cross Hospital2） Department of Cardiovascular Surgery, Nagano Red Cross Hospital

Bioprosthetic tricuspid valve stenosis is extremely rare. We report the case of a 54-year-old man with ahistory of infectious endocarditis (IE) and two previous tricuspid valve replacements (TVRs). The first TVR atage 25 was performed secondary to IE using a Star-Edwards Ball Valve. The repeat-TVR using a St. Jude
Medical Epic bioprosthesis was performed at age 51 due to severe ball valve stenosis. Repeat surgical valve re­placement is an extremely high-risk procedure. Percutaneous transcatheter tricuspid balloon valvuloplasty(PTTBV) is an acceptable treatment option for symptomatic severe tricuspid valve stenosis. There have been
few reports of successful PTTBV performed after bioprosthetic TVR. Successful treatment with PTTBV for bi­
oprosthetic tricuspid valve stenosis was achieved without complications in this patient. We believe that PTTBV
can be performed either as a destination therapy or as a bridge to TVR. Shinshu Med J 67 : 289―292, 2019
(Received for publication December 27, 2018 ; accepted in revised form April 25, 2019)
Key words : percutaneous transcatheter tricuspid balloon valvuloplasty,
stenosed bioprosthetic tricuspid valve, tricuspid valve replacement

ⅠIntroduction

There are few case reports of successful percuta­

enced a gradual improvement.
ⅡCase Reportneous transcatheter tricuspid balloon valvuloplasty

A 54-year-old man was admitted because of oligu­(PTTBV) to manage bioprosthetic tricuspid valve

ria, exertional dyspnea, abdominal distension, and(TV) stenosis. Reviews of previously reported cases

bilateral leg edema over the previous 2 months. He

have suggested that PTTBV for bioprosthetic TV

had a history of infectious endocarditis (IE) at age

stenosis is effective and is associated with low mor­

20. TVR using a Star-Edwards Ball Valve was per­1）bidity . However, the PTTBV technique is not estab­

formed at age 25 for tricuspid stenosis (TS). He de­lished.

veloped severe ball valve stenosis and underwent aThe present report describes the case of a Japanese

repeat-TVR using a St. Jude Medical Epic biopros­

man with bioprosthetic TV stenosis and two priorthesis (27 mm) at age 51. On admission, physical ex­

tricuspid valve replacements (TVRs) who was suc­amination revealed bilateral lower extremity edema

cessfully treated with PTTBV without complications.

and hepatosplenomegaly. There was a Levine III/VI

In most cases, patients improve immediately after

diastolic rumble at the lower left sternal border. The

PTTBV ; however, the patient in this case experi­

electrocardiogram showed atrial fibrillation and＊Corresponding author : Toshinori Komatsu
Department of Cardiology, Nagano Red Cross Hospital,
5-22-1 Wakasato, Nagano, Nagano 380-8582, Japan
E-mail : komatsu.toshinori@gmail.com

No. 5, 2019echocardiography revealed severe TS with trivial
regurgitation. The leaflets were thickened and im­mobile. The mean diastolic gradient across thetricuspid valve was 12.3 mmHg, with a peak gradi­
289

Komatsu・Miyashita・Kanai et al.

CA

300
200100LVEDV (ml)0(mL)

LVESV (ml)

6040

B

20LAD (mm)0(mm), (%)

EF (%)

15IVC (mm)mean TVPG (mmHg)

1050(mmHg) -750

-141103090120150(post PTTBV day)Fig. 1
Ａ：Parasternal short-axis tomogram at the aortic valve level showing tricuspid jet velocity recorded using continuouswave Doppler. The jet velocity of 2.1 m/s corresponded to a maximum trans-tricuspid pressure gradient of 17.9mmHg and a mean gradient of 12.3 mmHg.
Ｂ：After balloon valvuloplasty, the maximum trans-tricuspid pressure gradient decreased from 17.9 mmHg to 11mmHg and the mean gradient decreased from 12.3 mmHg to 8.6 mmHg.
Ｃ：Ultrasonic Cardiogram (UCG) follow-up from repeat TVR to post-PTTBV day 150. Post-PTTBV values for LVEDP,LVESV, and mean TVPG gradually improved.
TVR : tricuspid valve replacement ; PTTBV : percutaneous transcatheter tricuspid balloon valvuloplasty ; LVEDP :end-diastolic volume ; LVESV : left ventricular end-systolic volume ; LAD : left atrial dimension ; EF : ejection fraction ;IVC : inferior vena cava ; mean TVPG : mean tricuspid valve pressure gradientent of 17.9 mmHg and an estimated tricuspid valve
2

gradient across the tricuspid valve, right atrial

area of 0.8 cm (Fig. 1A-C). His left ventricular ejec­pressure, and right ventricular end-diastolic pres­tion fraction was preserved. The initial therapy con­sure were measured and found to be 4.4, 13, and 11

sisted of a diuretic and dopamine, but he became

mmHg, respectively (Fig. 2A, C). The valve was di­anuric and hypotensive. He had not taken his war­

lated sequentially using a 10×40 mm MustangTM

farin for a long time, so we restarted warfarin thera­

Balloon Dilatation Catheter (Boston Scientific, Marl­py. Continuous hemodiafiltration and a continuous

borough, MA, USA), followed by a 14×40 mm XXL

infusion of dopamine (＞ 10 mcg/kg/min) wereBalloon Dilatation Catheter (Boston Scientific) underrequired to maintain his renal function and blood

fluoroscopic guidance (Fig. 3A-C). There were nopressure. Repeat surgical valve replacement wasimmediate complications. Tricuspid regurgitation

discussed, but he was considered to be high-risk for

was not observed, but the tricuspid gradient did not2）

morbidity and mortality . The patient was also notchange immediately. However, after PTTBV, his

willing to undergo another cardiac operation. We

symptoms gradually improved, body weight de­decided to perform PTTBV to reduce the gradientcreased from 68kg to 62 kg, the diastolic rumble im­across the bioprosthetic tricuspid valve after ob­

proved from Levine Ⅲ / Ⅵ to Ⅰ / Ⅵ , lower extrem­

taining approval from the ethics committee. During

ity edema was improved, and catecholamine ad-the right heart catheterization, the mean diastolic

ministration was tapered. Moreover, three days

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Vol. 67PTTBV of a stenosed bioprosthetic TVA

B

C

Pre

Post

(POD14)

mean RAP(mmHg)

13

2

s-RVP
(mmHg)

41

13

RVEDP
(mmHg)

111

max d-PGTV(mmHg)

7

3.5

mean d-PGTV(mmHg)

4.4

2.4

Fig. 2
Ａ：Before percutaneous transcatheter tricuspid balloon valvuloplasty (PTTBV), the mean diastolic pressure gradientacross the tricuspid valve (d-PGTV) is 4.4 mmHg. The mean right atrial pressure is 12 mmHg, and the rightventricular end-diastolic pressure is 9 mmHg.
Ｂ：After PTTBV day14, the mean d-PGTV, the mean right atrial pressure and the right ventricular end-diastolicpressure decreased.
Ｃ：Comparison of pre- and post-PTTBV RHC data. Post-PTTBV the RHC parameters did not immediately improve ;however, on post-PTTBV day14, the patient’s symptoms and RHC data improved.
RAP : right atrial pressure ; s-RVP : systolic right ventricular pressure ; RVEDP : right ventricular end-diastolic pressure ;d-PGTV : diastolic pressure gradient across the tricuspid valve ; RHC : right heart catheterization

AB

CFig. 3
Ａ：Fluoroscopic image demonstrating the 0.035- inch guide wire that was passed through the stenotic
bioprosthetic valve (arrow-head).
Ｂ：Initial balloon valvuloplasty is performed by manual inflation of a balloon with a diameter of 10×40 mm.
Ｃ：Final balloon inflation is performed by manual inflation of a balloon with a diameter of 14×40 mm.

post PTTBV, he did not need hemodialysis.

month follow-up. He had no symptoms, but there

Fourteen days later, another right heart catheter­

was a gradual worsening of his EF, left ventricularization was performed. The mean diastolic gradientend-diastolic volume, and left ventricular end-sys­across the tricuspid valve, right atrial pressure, andtolic volume (Fig. 1C).

right ventricular end-diastolic pressure decreased to2.4, 2, and 1 mmHg, respectively (Fig. 2B, C). HisⅢDiscussion

renal function gradually improved and he was dis­

PTTBV can be considered in patients with severe,charged in stable condition, remaining well at his 6-

symptomatic, native TS without TR, as a class ⅡbNo. 5, 2019291

Komatsu・Miyashita・Kanai et al.

guideline indication3）. Few PTTBV cases have been1）

potential complications. We supposed that the use ofreported , but, to the best of our knowledge, graduala small size balloon led to insufficient thrombus

improvement after a PTTBV procedure has never

crumbling. Therefore, TS improved gradually after

been reported. The number of years since the original

PTTBV. Since RV pressure was decreased, the pos­bioprosthetic tricuspid valve implantation in patientssibility of the effect of hemodialysis and diuretic

who underwent PTTBV ranged from 0.5 to 40 years

cannot be denied (Fig. 2C). While PTTBV may be a1）(mean, 11.2±10.3 yr. median, 9.0 yr.) . Our patientreasonable therapeutic option for stenotic biopros­

developed TS in only 3 years. We hypothesized thatthetic TVs, in some cases the effects have lasted

the small diastolic gradient across the TV and insuf­

only a few months. It is unclear why our patient’s

ficient warfarin effect may have affected the throm­

ejection fraction (EF) worsened temporarily after thebogenesis of the bioprosthetic valve. Bioprosthetic

PTTBV. At present, our patient is asymptomatic ;valve dysfunction results from leaflet calcification,

however, he has experienced a gradual worsening ofthrombosis, pannus ingrowth or vegetation. Balloon

his EF, left ventricular end-diastolic volume and leftvalvuloplasty works by crumbling thrombus, tearing

ventricular end-systolic volume (Fig. 1C). Therefore,

leaflets and perforating cusps, as seen in vitro, in

we must continue long-term follow-up of this patient.

studies performed on stenotic porcine bioprosthetic

Ⅳvalves4）.

Conclusion

Almost all cases of PTTBV have been successful,

Bioprosthetic TV stenosis is rare. Successful treat­1）

with only one unsuccessful procedure reported ;ment without complications has been achieved withhowever, other cases with unfavorable results may

PTTBV in patients with bioprosthetic TV stenosis.

exist, but may not have been published. A variety ofPTTBV could be an alternative to operative valve

interventional techniques were used in previous

replacement in high-risk surgical patients.

reports, with balloon sizes ranging from15 to 30 mm.

ⅤWe used a 14 mm balloon because we had no previ­
ous PTTBV experience and were concerned about

Conflict of Interest

The authors declare no conflict of interest.

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（2018. 12. 27 received；2019. 4. 25 accepted）

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