Tricuspid Valve-in-Valve Procedure: What to Do When the Bioprosthetic Valve is Not Visible on Fluoroscopy? Challenges and Step-by-Step Description of the Procedure

The main disadvantage of bioprosthetic heart valves is the development of degeneration in the medium to long term. Due to the high-risk of reoperation, the percutaneous valve-in-valve (ViV) approach is preferred in patients with bioprosthetic degeneration following tricuspid valve replacement. When the implanted bioprosthetic valve is not radio-opaque, the procedure can be challenging. We aim to present three cases performed at our hospital, describe the procedure step-by-step and how alignment is achieved when the valve is not visible on fluoroscopy. Patients admitted with right heart failure exhibited severe dysfunction in their tricuspid bioprosthetic valves. In the first case the bioprosthesis valve was clearly visible on fluoroscopy, facilitating the alignment process. However, the bioprosthetic valves of the other two patients were not visible on fluoroscopy. Predilation was performed and the indentation line served as a reference. ECHO imaging and right atrial/ventricular angiograms were performed while aligning the balloon-expandable valve. ViV procedure was successful in all 3 cases. The transcatheter ViV procedure appears to be a good treatment option for patients with tricuspid bioprosthetic valve degeneration. In instances where the valve is not radio-opaque, the procedure can be executed by carefully considering the indentation point during balloon dilatation, right ventriculography, right atrial angiography and along with transthoracic or transesophageal echocardiography during the alignment of the new valve.