Noninvasive pacing during transfemoral implantation of the Edwards SAPIEN valve for tricuspid valve bioprosthesis stenosis

Introduction

Transcatheter implantation of balloon expandable valves in high-risk patients with degenerated tricuspid bioprostheses has been reported since 2010 [1, 2]. Although there have been cases where the SAPIEN valve was implanted in the tricuspid position without rapid pacing [3, 4], invasive rapid ventricular pacing is usually applied during valve deployment.
We present a case report documenting for the first time the use of noninvasive, external rapid pacing delivered through defibrillation sticker-pads during transfemoral implantation of the Edwards SAPIEN XT valve for tricuspid valve bioprosthesis stenosis.

Case report

A 76-year-old woman with a history of rheumatic fever was treated at the age of 21 with open mitral commissurotomy. In 1995, at the age of 57 she underwent simultaneous triple valve replacement with mechanical aortic (21-mm Sorin Bicarbon; Sorin Biomedica, Saluggia, Italy), mitral (27-mm St. Jude medical valve; St. Jude Medical Inc., St. Paul, MN) prostheses and a tricuspid bioprosthesis (TBP) (29-mm Intact Valve; Medtronic Inc, Minneapolis, MN, USA). For the last 2 years she had experienced a decline in exercise tolerance and peripheral edema. At the beginning of 2015 she presented to our department with the New York Heart Association (NYHA) functional class III/IV and right heart failure. Despite aggressive treatment she continued to deteriorate. Her other medical history included paroxysmal atrial fibrillation, hypertension, chronic obstructive pulmonary disease, previous surgery for brain meningioma and right sided mastectomy for breast cancer. Echocardiography showed severe TBP stenosis with trace regurgitation and normal function of both mechanical valves. The mean and peak tricuspid gradient was 22 mm Hg and 34 mm Hg respectively. The left ventricle was not dilated, with preserved systolic function. The inner TBP diameter was measured at 21–22 mm by computed tomography and 20–21 mm by echocardiography. The heart team agreed that operative risk was prohibitive (calculated EuroSCORE II and logistic EuroSCORE were respectively 7.99% and 22.76%) and transvenous tricuspid valve-in-valve implantation would be a possible life-saving option.

Procedure

The procedure was carried out in general anesthesia and with 3D transesophageal echocardiography (3D TEE) guidance. Right femoral venous access was used. The TBP was crossed with a 6 Fr multipurpose catheter placed within a Transseptal Guiding...


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