Successful implantation of an EVOQUE-Tricuspid Valve Replacement System in a patient with two right ventricular ICD leads

Introduction

Tricuspid regurgitation (TR) is a common valvular heart disease with significant morbidity and mortality rates. Tricuspid valve transcatheter edge-to-edge repair (T-TEER) is limited in patients with massive or torrential TR and/or a large coaptation gap. Transcatheter tricuspid valve replacement (TTVR) is a new treatment option for TR. The only TTVR option with FDA and CE-mark approval currently available is the EVOQUE tricuspid valve replacement system. Its good procedural safety and favorable clinical outcomes at one year have recently been reported.

We report a case of a patient who underwent successful TTVR with the EVOQUE prosthesis despite having two right ventricular (RV) cardioverter-defibrillator (ICD) leads.

Case presentation

An 82-year-old patient presented at our tertiary care center with acute decompensated heart failure. Transesophageal echocardiography (TEE) after decongestion revealed a torrential TR (Grade V) with a large central coaptation gap of the leaflets of >8mm. The further medical history of the patient included left heart failure with improved ejection fraction based on dilated cardiomyopathy, permanent atrial fibrillation, surgical aortic valve replacement (SAVR) and mitral valve reconstruction (MVR). The patient had a CRT-D implanted. During a replacement the RV lead could not be retrieved and thus a second shock lead was implanted.

The case was discussed in our interdisciplinary heart team and was regarded as unsuitable for T-TEER due to the presence of two ICD leads or surgical therapy because of the high surgical risk.

Intervention

The procedure was carried out under general anesthesia. After obtaining vascular access, a 52mm EVOQUE prosthesis was advanced over a Safari wire into its position in the tricuspid valve anulus. A capsule gap was created to evaluate the depth of the prosthesis in the right ventricle. Definitive decision to implant the prosthesis despite the challenging anatomy and the severely impeded echocardiographic view (due to prior SAVR and MVR, see fig. 1) was made after a final discussion with all team members. Echocardiographic guidance was performed using mid- and deep-esophageal as well as transgastric views in biplane 2D and 3D-multiplanar reconstruction.

Postprocedural transthoracic echocardiography showed no valvular regurgitation and only minimal paravalvular leakage (PVL) around the ICD-coils (TR trace), which could be seen jailed between the prosthesis and the RV wall. Mild regurgitation (VC <3mm) of the previously reconstructed mitral valve could be seen. Postprocedural interrogation of the ICD revealed normal device function with normal impedances, pacing threshold and regular sensing.

Discussion

Recent studies have shown that TTVR is a feasible option, even in patients with RV ICD leads. We present the case of a patient who had not one, but two ICD leads and was successfully treated by TTVR. The EVOQUE prosthesis uses anchor-like structures to secure its position within the anulus. These anchors do not exert significant pressure on the annulus or the sub-valvular structures. Therefore, damage to pacemaker leads is highly unlikely. PVL is minimized by the intra-annular sealing skirt.

In our case the patient underwent successful TTVR despite the difficulties in echocardiographic imaging caused by the significant amount of alien material.

The patient left our hospital a few days after the procedure in good overall condition and is scheduled for regular workups.