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 their potential for degeneration in the medium to long term. Due to the high risk associated with reoperation, the percutaneous valve-in-valve (ViV) approach is preferred for patients with bioprosthetic degeneration following tricuspid valve replacement. However, the procedure can be challenging when the implanted bioprosthetic valve is not radio-opaque. We present three cases performed at our hospital, detailing a step-by-step approach and alignment techniques when the valve is not visible on fluoroscopy. All patients were admitted with right heart failure and demonstrated severe dysfunction of their tricuspid bioprosthetic valves. In the first case, the bioprosthetic valve was clearly visible on fluoroscopy, which facilitated the alignment process. In the other two cases, the valves were not visible. Predilation was performed, and the resulting indentation line served as a reference. Echocardiographic (ECHO) imaging, along with right atrial and ventricular angiograms, was used to guide the alignment of the balloon-expandable valve. The ViV procedure was successful in all three cases. The transcatheter ViV approach appears to be an effective treatment option for patients with tricuspid bioprosthetic valve degeneration. In cases where the valve is not radio-opaque, the procedure can be safely performed by using the indentation point from balloon dilatation, right ventricular and atrial angiography, and transthoracic or transesophageal echocardiography to guide valve alignment.