Double Balloon Technique for Tricuspid Valvotomy After Bioprosthetic Valve Implantation
The double balloon technique is not recommended for tricuspid valvotomy after bioprosthetic valve implantation; instead, transcatheter valve-in-valve implantation is the preferred approach for failing bioprosthetic tricuspid valves in high-risk patients.
Current Approaches for Failing Bioprosthetic Tricuspid Valves
Balloon Valvotomy vs. Valve-in-Valve
- Balloon valvotomy is primarily indicated for native valvular stenosis with specific anatomical characteristics (domed pulmonary valve) and is not recommended for bioprosthetic valves 1
- Bioprosthetic valve degeneration typically results from leaflet calcification, tears, or perforations, which are not amenable to balloon valvotomy techniques 1
- Transcatheter valve-in-valve implantation has emerged as the preferred approach for failing bioprosthetic valves in high-risk patients 1, 2
Evidence for Transcatheter Valve-in-Valve Approach
- Case series have documented successful outcomes using transcatheter valve-in-valve implantation for degenerated tricuspid bioprosthetic valves 2, 3, 4
- This approach avoids high-risk repeat cardiac surgery in patients with multiple comorbidities 2
- A retrospective study of 10 patients who underwent transcatheter valve-in-valve implantation for degenerated tricuspid bioprosthetic valves showed significant clinical and functional improvement with no major complications 4
Technical Considerations
Double Balloon Technique
- While double-balloon procedures are used in native valve disease to achieve effective dilation (oversizing balloons up to 1.4 times the measured pulmonary annulus), this approach is not validated for bioprosthetic valves 1
- The double balloon technique works by commissural splitting, which is not applicable to the mechanism of stenosis in bioprosthetic valves 1
Valve-in-Valve Technique
- Transcatheter valve-in-valve implantation is performed under echocardiography and fluoroscopy guidance, typically via the transfemoral venous route 4
- Various balloon-expandable valves have been successfully used, including Edwards SAPIEN and Myval transcatheter heart valves 3, 4
- In cases where the inner diameter is too small, techniques such as cracking the ring of the bioprosthetic valve using ultrahigh pressure balloons have been reported to optimize placement of a larger percutaneous valve 5
Anticoagulation Considerations
Post-Procedure Management
- For bioprosthetic tricuspid valves, anticoagulation with vitamin K antagonists (VKAs) is recommended for 3-6 months after implantation (target INR 2-3), plus aspirin 1
- After this initial period, the risk of thromboembolic complications is low, and continued anticoagulation is not indicated in the absence of other risk factors 1
- The risk of systemic embolization from right-sided bioprosthetic valves is essentially nonexistent compared to left-sided valves 1
Follow-up Recommendations
Monitoring
- Periodic clinical follow-up is recommended for all patients after valve procedures, with specific attention to valve function, right ventricular pressure, size, and function 1
- Echocardiography should be performed within 30 days after valve implantation (baseline imaging), at 1 year, and annually thereafter 1
- The frequency of follow-up should be determined by the severity of hemodynamic abnormalities but should be at least every 5 years 1
Potential Complications and Management
Valve Dysfunction
- Potential complications after transcatheter procedures include valve thrombosis, paravalvular leak, and valve degeneration 1
- For bioprosthetic valve thrombosis, vitamin K antagonist therapy is recommended as first-line treatment unless contraindicated 1
- For severe symptomatic bioprosthetic valve stenosis in high-risk patients, a transcatheter valve-in-valve procedure is reasonable when improvement in hemodynamics is anticipated 1