Case and Plan:
77-year-old female presents with worsening dyspnea on minimal exertion, lower extremity edema, NYHA class III over the last few months. Past medical history is significant for HTN, HLD, COPD on 2L Oxygen, gout, Hodgkin’s Lymphoma in remission, HFrEF / NICM (likely adriamycin-induced), bleomycin-induced pulmonary toxicity, PAH, severe TR s/p TTVR (44 mm Evoque) on rivaroxaban.TTE showed no paravalvular leak, mean TV gradient of 6 mmHg at 93 bpm. The Evoque valve leaflets appeared thickened and likely thrombosed. The right ventricle appeared dilated with severely decreased function. EF was 23% with severely dilated left ventricle. Despite changing the anticoagulation to apixaban (intolerant of warfarin) for several months, the patient remained symptomatic. Repeat TTE/TEE showed persistent mean TV gradient of 5-6 mmHg at 89 bpm with severe RV dilation and dysfunction. LV EF improved to 45%. CT chest showed persistent thickening/hypoattenuation of the leaflets (HALT) and associated reduced leaflet motion (RLM). Patient was evaluated by the Heart Team and was deemed high risk for Evoque valve explant and surgical tricuspid valve replacement due to comorbidities and frailty. The patient is now planned for a tricuspid ViV TTVR with a 29mm SAPIEN-3 Ultra Resilia valve in a 44mm Evoque valve via transfemoral approach.
