Case report

Percutaneous pulmonary valve implantation is widely used to treat native or post-surgical right ventricular outflow tract dysfunction. ^{Reference Bonhoeffer, Boudjemline and Saliba1} Right ventricular outflow tract dysfunction leads to right ventricle dilation which in turn promotes dilation of the tricuspid annulus causing tricuspid regurgitation. If significant, tricuspid regurgitation can be surgically repaired with an annuloplasty ring. However, long-term results are not satisfactory, with more than 25% of patients developing moderate to severe regurgitation 5 years after surgical correction. For high-risk surgical patients, percutaneous implantation of a pulmonary valve in a tricuspid position, either valve-in-valve or valve-in-ring, is emerging as a lower risk solution. ^{Reference Aboulhosn, Cabalka and Levi2} We report on a successful simultaneous percutaneous valve implantation at both locations. To the best of our knowledge, this is the first report describing the simultaneous of Melody® pulmonary valves during the same procedure in the pulmonary and tricuspid positions, the latter a valve-in-ring implantation.

Fifty-year-old female with congenital severe pulmonary valve stenosis and atrial septal defect, previously submitted to several surgical procedures, namely, surgical pulmonary valvotomy at 6 years of age, followed by, at the age of 21 years, right atrial reduction plasty, implantation of a 25 mm bioprosthetic pulmonary valve and a 33 mm Carpentier-Edwards incomplete ring annulloplasty. She also had type 2 diabetes mellitus, hypothyroidism, atrial fibrillation, and she was in New York Heart Association (NYHA) I–II functional class of heart failure when the intervention was planned. However, in the context of lower limb erysipelas, she developed a septic and cardiogenic shock, complicated with renal failure. At the time of the procedure, she had recovered from the infection, albeit, maintaining severely reduced functional capacity, as well as being dependent on daily haemodialysis.

Multi-modality imaging examinations revealed mild right ventricular systolic dysfunction, severe right atrial dilation (300 ml/m²) (Fig 1a), right ventricular enlargement (end-diastolic volume of 155 mL/m², end-systolic volume of 80 mL/m²), central torrential tricuspid regurgitation (Fig 1b), tissue dehiscence adjacent to the opening part of the ring (Fig 1c) and severe pulmonary valve stenosis (peak Doppler systolic gradient of 85 mmHg).

Figure 1.

( a ) Cardiac magnetic resonance imaging, axial and coronal planes. Note the massive right atrium dilation. ( b ) 2D transesophageal echocardiography, four chambers view, colour Doppler mode. Carpentier ring in tricuspid position with massive tricuspid regurgitation through the ring. ( c ) 3D transesophageal echocardiography, mid-esophageal view. Carpentier ring seen from right atrium side. Note the tissue dehiscence adjacent to the opening part of the ring (arrow) (possibly overestimated due to very thin tissue drop-out artifact). Legend: Ao – Aorta; LA – left atrium; LV – left ventricle; PA – pulmonary artery; RA – right atrium; RV – right ventricle; TR – triscuspid regurgitation.

Left and right-heart catheterisation was carried out, and the right ventricle outflow tract angiogram confirmed severe bioprosthetic pulmonary valve stenosis with post-stenotic pulmonary artery dilation. The peak-to-peak pressure gradient was 50 mmHg, and the RV systolic pressure was greater than 75% of the left ventricle systolic pressure. We initially performed a percutaneous balloon pulmonary valvuloplasty with a 20/40 mm Atlas Gold balloon (BD®, United States of America). A 39 mm Bare CP Stent (NuMED®, United States) mounted on a 22/40 mm Atlas Gold balloon (BD®, United States) was then implanted. In order to further secure this stent and create a safe landing zone, an AndraStent XXL 48 mm (Andramed®, Germany) mounted on a 24/60 mm Andraballoon (BD®, United States of America) was also implanted. This was followed by successful implantation of a 22 mm Melody valve (Medtronic®, United States of America) in pulmonary position. Despite the immediate optimal result, with no pulmonary regurgitation, tricuspid regurgitation remained significant as confirmed by transesophageal echocardiography. As the mechanism of tricuspid regurgitation was considered to be due to a major coaptation gap with leaflet tethering mainly through the tricuspid ring, we then proceeded with a valve-in ring implantation with a 22 mm Melody valve (Medtronic®, United States of America) in the tricuspid position under 3D-echocardiography guidance and balloon sizing, with good overall result (Fig 2a). Nonetheless and as expected, a moderate paravalvular leak at triscuspid position was observed post-implantation (Fig 2b). The patient was discharged home 1 week later with progressive improvement of the heart failure functional class (NYHA I 3 months later).

Figure 2.

( a ) Catheterisation fluoroscopy, anteroposterior view. Two 22 mm Melody® valves implanted in the pulmonary position (valve-in-valve, upper valve) and in tricuspid position (valve-in-ring, lower valve). ( b ) 2D transesophageal echocardiography colour doppler mode, four chambers view. Melody® valve implanted successfully inside carpentier ring with moderate paravalvular leakage. Legend: * – paravalvular leakage; RA – right atrium; RV – right ventricle.