International Society For Minimally Invasive Cardiothoracic Surgery

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The Importance Of Pre-operative Imaging And 3-d Printing In Transcatheter Tricuspid Valve-in-valve Replacement
Luigi Pirelli, MD, Dillon Weiss, Nirav C. Patel, MD, Derek R. Brinster, MD, Jonathan M. Hemli, MD, Jacob S. Scheinerman, MD, Chad A. Kliger, MD.
Lenox Hill Hospital, New York, NY, USA.

OBJECTIVE: To show the relevance of multimodality imaging and pre-operative testing in planning and conducting a percutaneous transcatheter tricuspid valve-in-valve intervention.
METHODS: A prerequisite to complex transcatheter procedures is adequate pre- and intra- procedural imaging. Trans-esophageal echocardiogram, volume-rendered 3D gated Computed Tomography Angiography (CTA), fluoroscopy and 3-D printing are all useful tools in the hands of interventional cardiologists and surgeons to plan the procedure, identify optimal access, choose the adequate prosthesis and perform an intervention minimizing its risks and complications. Recently, great interest has been growing in the field of tricuspid valve (TV) transcatheter procedures. Valve-in-valve (VIV) percutaneous approach has been recently demonstrated to be an effective treatment in non-operable or high risk patients who have a degenerated bioprosthetic tricuspid valve in place. The majority of published data are single case-reports, comparing results of different balloon expandable valves and different accesses (transjugular or transfemoral).
RESULTS: We successfully performed a tricuspid VIV procedure in a 44-year-old female patient with failing tricuspid bioprosthesis and a well-functioning mechanical mitral valve, deemed high risk for an open surgical approach. Preoperatively, both CTA with 3-D reconstruction and 3-D printing of the patientís heart were performed. These tests allowed us to optimally plan our procedure by addressing 3 major technical concerns: 1) the approach, transjugular or transfemoral, measuring the angle between the inferior vena cava and the TV; 2) the angle of deployment, finding adequate coaxiality between the stiff guidewire and the annular plane; 3) the choice of the prosthesis (balloon- or self- expandable), and its size. Not only the gated CTA allowed us to make all the appropriate measurements, but also the 3-D print of the patientís heart made possible to simulate catheters manipulation and valve deployment in the lab in order to improve and ameliorate all technical aspects.
CONCLUSIONS: Preoperative imaging workup has a key role in planning and conducting a transcatheter procedure. 3-D printing is a novel tool that in addition to CTA and echocardiography, can help improving accuracy and efficacy of transcatheter interventions.


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