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How should I treat prosthetic tricuspid stenosis in an extreme surgical risk patient?

BACKGROUND
A 64-year-old female with rheumatic heart disease and multiple prior valve replacements presented with progressive oedema, ascites and dyspnoea on exertion.


INVESTIGATION
Physical examination, transthoracic echocardiography, intracardiac echocardiography, transoesophageal echocardiography, right heart cathetherisation, computed tomography.


DIAGNOSIS
She had a mitral homograft and Physio ring in the tricuspid position, and presented with severe bioprosthetic tricuspid valve stenosis (mean gradient 16 mmHg) and right-sided heart failure.


TREATMENT
A transcatheter 26 mm Edwards SAPIEN valve was placed in the tricuspid position, resulting in near normalisation of tricuspid valve gradient. This represents the first report of a combined valve-in-ring (VIR) and valve in a homograft valve (VIV) SAPIEN implantation.