This Article Extract Full Text (PDF) Data Supplement Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Yunoki, K. Articles by Haze, K. Search for Related Content PubMed PubMed Citation Articles by Yunoki, K. Articles by Haze, K. Related Collections Other heart failure Valvular heart disease Catheter-based coronary and valvular interventions: other Related Article

(Circulation. 2006;114:e558-e559.)
© 2006 American Heart Association, Inc.

Images in Cardiovascular Medicine

Percutaneous Transcatheter Balloon Valvuloplasty for Bioprosthetic Tricuspid Valve Stenosis

Kei Yunoki, MD; Takahiko Naruko, MD; Akira Itoh, MD; Junko Ohashi, MD; Kohei Fujimoto, MD; Naoya Shirai, MD; Koichi Shimamura, MD; Ryushi Komatsu, MD; Yuji Sakanoue, MD; Kazuo Haze, MD

From the Department of Cardiology, Osaka City General Hospital, Osaka, Japan.

Correspondence to Takahiko Naruko, MD, Department of Cardiology, Osaka City General Hospital, 2-13-22, Miyakojima-hondori, Miyakojima-ku, Osaka, 534–0021, Japan. E-mail tmnaruko{at}msic.med.osaka-cu.ac.jp

A 59-year-old woman was admitted to our hospital because of exertional dyspnea, abdominal distension, and leg edema over the past 2 weeks. She had a history of rheumatic fever at the age of 12 years. In 1983, at the age of 37, she had undergone tricuspid valve replacement with a Carpentier-Edwards bioprosthesis for tricuspid stenosis and mitral valve replacement with a mechanical valve for mitral stenosis. The physical examination on admission revealed marked edema in both legs. There was also presystolic pulsation of the liver, which was palpable 4 cm below the right costal margin. A Levine grade III/VI, rough, diastolic rumble at the lower left sternal border was accentuated during inspiration. Echocardiography revealed severe tricuspid stenosis and a large amount of ascites. The leaflets were thickened, shortened, and immobile, resulting in a fixed orifice in systole and diastole. The mean diastolic gradient across the tricuspid valve was 14.1 mm Hg, with a peak gradient of 23.0 mm Hg during early diastole (Figure 1A). Tricuspid regurgitation was mild (Figure 1B and online-only Data Supplement Movie I), and there was no aortic or mitral valve pressure gradient. Initial therapy consisted of a diuretic for right-sided heart failure, but it did not relieve her ascites or leg edema. Therefore, we performed percutaneous transcatheter balloon valvuloplasty to reduce the gradient across the bioprosthetic tricuspid valve (Figure 2A and 2B and Movies II and IIII). During right heart catheterization, the right atrial tracing revealed a prominent A wave (24 mm Hg), with a mean diastolic gradient across the tricuspid valve of 13 mm Hg (Figure 2C). After the balloon valvuloplasty, the mean diastolic gradient across the tricuspid valve decreased to 6 mm Hg (Figure 2D). Echocardiography showed that the mean diastolic gradient across the tricuspid valve decreased to 7.0 mm Hg without worsening of tricuspid regurgitation (Figure 1C and 1D and Movie IV). The patient’s symptoms immediately improved and the ascites disappeared. The present report demonstrates the successful use of percutaneous transcatheter balloon valvuloplasty for bioprosthetic tricuspid valve stenosis.

View larger version (72K): [in this window] [in a new window]   Figure 1. A, Color flow imaging in an apical 4-chamber view shows the tricuspid stenosis jet and the tricuspid jet velocity, recorded with continuous-wave Doppler. The jet velocity of 2.4 m/s corresponded to a maximum transtricuspid pressure gradient of 23.0 mm Hg and a mean gradient of 14.1 mm Hg. B, Before the procedure, color flow imaging in the apical 4-chamber view showed mild tricuspid regurgitation (Movie I). RV indicates right ventricle; RA, right atrium. C, After balloon valvuloplasty, the maximum transtricuspid pressure gradient decreased from 23.0 mm Hg to 13.0 mm Hg and the mean gradient decreased from 14.1 mm Hg to 7.0 mm Hg. D, After the procedure, color flow imaging in the apical 4-chamber view showed no worsening of tricuspid regurgitation (Movie IV).

View larger version (69K): [in this window] [in a new window]   Figure 2. A, Fluoroscopic image in the right anterior oblique/cranial view demonstrates the guide wire that was passed through the center of the stenotic bioprosthetic valve (Movie II). Mechanical mitral valve (black arrow) and bioprosthetic tricuspid valve (yellow arrow) are shown. B, Balloon valvuloplasty was performed with the use of a balloon with a maximum diameter of 25 x 40 mm and an inflation pressure of 16 atm (Movie III). C, Before the procedure, the mean right atrial pressure was 21 mm Hg and the right ventricular end-diastolic pressure was 5 mm Hg. The mean diastolic gradient across the tricuspid valve was 13 mm Hg. D, After the procedure, the mean right atrial pressure was 12 mm Hg and the right ventricular end-diastolic pressure was 10 mm Hg. The mean diastolic gradient across the tricuspid valve was improved to 6 mm Hg. Abbreviations as in Figure 1.

	Acknowledgments

 
Disclosures

None.

	Footnotes

 
The online-only Data Supplement, which includes 4 movies, is available with this article at http://circ.ahajournals.org/cgi/content/full/114/18/e558/DC1.

Related Article:

Issue Highlights
Circulation 2006 114: 1897. [Extract] [Full Text]

This Article Extract Full Text (PDF) Data Supplement Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Yunoki, K. Articles by Haze, K. Search for Related Content PubMed PubMed Citation Articles by Yunoki, K. Articles by Haze, K. Related Collections Other heart failure Valvular heart disease Catheter-based coronary and valvular interventions: other Related Article