Three-dimensional intracardiac echo-guided transcatheter tricuspid valve replacement

A 73-year-old female with a history of rheumatic fever and severe mitral stenosis who had undergone a valve-in-mitral annular calcification (ViMAC) transcatheter mitral valve replacement (TMVR) with a 26 mm SAPIEN 3 Ultra valve (Edwards Lifesciences) 5 years prior, presented with New York Heart Association (NYHA) Class III symptoms. Transoesophageal echocardiography (TOE) demonstrated a well-functioning mitral transcatheter heart valve (THV) (Figure 1A) with mild paravalvular leak (PVL) (Figure 1B). Transthoracic echocardiography (TTE), however, revealed severe tricuspid regurgitation (TR) (Figure 1C). TOE imaging of the tricuspid valve was markedly impaired due to acoustic shadowing from the mitral THV frame and calcified annulus, which severely limited leaflet visualisation (Figure 1D, Figure 1E, Moving image 1, Moving image 2).

Given the high surgical risk, the Heart Team proceeded with transcatheter tricuspid valve replacement (TTVR) with a 44 mm EVOQUE valve (Edwards Lifesciences) via right femoral venous access under general anaesthesia. Despite the limited TOE imaging (Figure 1F, Figure 1G, Moving image 3), a three-dimensional...