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When Percutaneous Tricuspid Valve Replacement Fails: A Minimally Invasive Surgical Rescue
Catarina Novo, Mariana Campos, Belisa Gomes, Daniel Martins, Nelson Santos, Paulo Neves.
ULSGE, Vila Nova de Gaia, Portugal.
BACKGROUND: As percutaneous valvular procedures continue to expand, Heart Team physicians must be prepared to manage potentially severe complications. We present a case of a life-threatening complication following percutaneous tricuspid valve replacement that was managed through minimally invasive cardiac surgery in a patient with prior coronary surgery.
METHODS: A 79-year-old man with severe tricuspid regurgitation, right ventricular failure, and a history of previous coronary artery bypass grafting underwent percutaneous tricuspid valve replacement. The procedure failed due to improper anchoring of the prosthesis to the native valve leaflets, resulting in embolization of the device into the right atrium. The patient was referred for emergent cardiac surgery. Given his frailty, multiple comorbidities, and the need to avoid a high-risk redo sternotomy, a minimally invasive approach was selected. Surgery was performed through a right thoracotomy with peripheral cannulation. After removal of the embolized prosthesis, the native tricuspid valve was deemed irreparable, and as a rescue strategy, a biological mitral prosthesis was implanted in the tricuspid position.
RESULTS: The prosthesis was successfully implanted with no immediate residual leak or regurgitation. Although the patient was initially weaned from cardiopulmonary bypass, he developed severe postoperative right ventricular dysfunction requiring mechanical circulatory support with a dual-lumen cannula, providing right atrial drainage and pulmonary artery return. Mechanical support allowed partial recovery of right ventricular function; however, after decannulation, significant regurgitation of the tricuspid prosthesis was detected. During prolonged postoperative intensive care, the patient developed nosocomial pneumonia and subsequently died from infectious complications.
CONCLUSIONS: This case highlights a growing and complex challenge faced by cardiac surgeons: patients previously considered inoperable who develop catastrophic complications after percutaneous interventions that ultimately require surgical rescue. In the setting of prior cardiac surgery, minimally invasive right thoracotomy may represent a valuable alternative to redo sternotomy when performed in experienced centers. This case underscores that, in extremely frail patients, technical surgical success does not necessarily translate into survival, emphasizing the importance of patient selection and postoperative multidisciplinary management.
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