Early leaflet thrombosis complicating transcatheter implantation of a Sapien 3 valve in a native right ventricular outflow tract.

A 59-year-old female with Tetralogy of Fallot had a previous complete repair with RVOT patch enlargement. She developed subsequent severe symptomatic (NYHA III) pulmonary regurgitation with severe RV dilatation. She had a concomitant interstitial lung disease secondary to hypersensitivity pneumonitis that precluded her from cardiac surgery. After preprocedural assessment using computed tomography, echocardiography and invasive angiography we decided to implant a 29 mm Edwards Sapien 3 valve without pre-stenting. The Sapien 3 valve was implanted in a satisfactory position using rapid RV pacing. The valve appeared well expanded with good circularity on fluoroscopy. A transthoracic echocardiography on the following day showed no pulmonary regurgitation with a peak gradient of 14 mmHg across the prosthesis. At 4 weeks follow-up, the patient felt a marked improvement (NYHA II) but a CT scan showed bileaflet valve thickening with preserved stent expansion. A concomitant echo-doppler showed a significant increase of peak pulmonary gradient to 26 mmHg. After a six weeks course of warfarin therapy, the transpulmonary valve peak gradient came down to 16 mmHg and leaflet thickening resolved on CT. The Sapien 3 system helped achieve a successful transfemoral percutaneous pulmonary valve implantation in a challenging native RVOT anatomy. This case was complicated by early valve thrombosis as documented by CT and was successfully treated with oral anticoagulation.