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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 8  |  Issue : 3  |  Page : 182-184

Bioprosthetic tricuspid valve stenosis in a case of rheumatic mitral valve stenosis and tricuspid valve replacement


1 Assistant Professor in Department of Cardiology, Government Medical College and Hospital, Aurangabad, India
2 Professor and HOD at Department of Cardiology, Bombay Hospital Institute of Medical Sciences, Mumbai, Maharashtra, India

Date of Submission30-Aug-2022
Date of Decision23-Nov-2022
Date of Acceptance26-Nov-2022
Date of Web Publication20-Dec-2022

Correspondence Address:
Ganeshrao Patilba Sapkal
Department of Cardiology, Government Medical College and Hospital, Aurangabad - 431 001, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jpcs.jpcs_53_22

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  Abstract 


Very little is known about the occurrence of bioprosthetic tricuspid valve stenosis in the Indian population that usually occurs within 8–10 years following tricuspid valve replacement (TVR) with a bioprosthetic valve. Here, we present a case of a 43-year-old woman suffering from chronic rheumatic heart disease who underwent prior two open mitral valvotomies and a TVR, now presented with severe mitral regurgitation and severe bioprosthetic tricuspid valve stenosis.

Keywords: Bioprosthesis, mitral regurgitation, rheumatic heart disease, tricuspid valve stenosis


How to cite this article:
Sapkal GP, Sharma S. Bioprosthetic tricuspid valve stenosis in a case of rheumatic mitral valve stenosis and tricuspid valve replacement. J Pract Cardiovasc Sci 2022;8:182-4

How to cite this URL:
Sapkal GP, Sharma S. Bioprosthetic tricuspid valve stenosis in a case of rheumatic mitral valve stenosis and tricuspid valve replacement. J Pract Cardiovasc Sci [serial online] 2022 [cited 2023 Feb 3];8:182-4. Available from: https://www.j-pcs.org/text.asp?2022/8/3/182/364546




  Introduction Top


Tricuspid stenosis (TS) can occur in conjunction with mitral stenosis in patients with rheumatic heart disease (RHD). Yet it is clinically significant in seldomly 5% of patients.[1] There are several conditions such as congenital heart disease, pacemaker lead insertion across the tricuspid valve, inflammatory diseases, radiation, infective endocarditis with extensive vegetations, and carcinoid syndrome that lead to the development of TS.[2] Stenosis of bioprosthetic tricuspid valve is an uncommon but significant late sequela following the replacement of the tricuspid valve with a bioprosthetic valve.[3] Surprisingly, the clinical diagnosis of bioprosthetic tricuspid valve stenosis remains a hurdle even for the most experienced clinicians. Here, we report an unusual presentation of a 43-year-old woman with chronic RHD who had undergone prior two open mitral valvotomies (OMVs) and a tricuspid valve replacement (TVR). At this time, she was presented with severe mitral regurgitation (MR) and severe bioprosthetic tricuspid valve stenosis.


  Case Report Top


The patient was a 43-year-old woman who underwent OMV for severe mitral stenosis at the age of 15 years in 1987. She underwent a repeat OMV with TVR using a 31 mm Carpentier-Edwards bioprosthetic valve at the age of 26 years in 1998. However, the indication for TVR was not known. She was on oral anticoagulation and was relatively asymptomatic for 9–10 years after her second surgery. Afterward, she developed gradual onset of dyspnea which progressed over the next 5–6 years.

The patient was referred to our institution with complaints of New York Heart Association class III dyspnea and palpitations in 2015. She had hypothyroidism and chronic atrial fibrillation as additional comorbidities. Her vital signs at presentation were as follows: an irregular pulse of 66 beats/min, blood pressure of 110/70 mm Hg, a raised jugular venous pressure with a slow y descent, and mild edema feet. Cardiac percussion revealed the right heart border by 5 cm beyond the mid sternum. On auscultation, a Grade III/VI pansystolic murmur at the apex was present as well as a Grade II/IV middiastolic murmur at the lower left sternal border with inspiratory augmentation was audible. There was hepatomegaly with palpable liver pulsations. There were no added breath sounds.

Electrocardiogram revealed atrial fibrillation with controlled ventricular rate. Chest X-ray showed cardiomegaly with enlarged right atrium (RA), left atrium (LA), and a bioprosthetic tricuspid valve ring [Figure 1]. Echocardiography revealed markedly dilated RA, dilated LA and inferior vena cava, severe MR, and severe bioprosthetic tricuspid valve stenosis with tricuspid valve area by continuity equation 1.1 cm2 and peak/mean gradients of 16/7 mm Hg across the valve (average of five beats) [Figure 2]. There was mild tricuspid regurgitation, mild pulmonary hypertension, and reduced biventricular function. Cardiac catheterization demonstrated grade 4/4 MR, severe bioprosthetic tricuspid valve stenosis with a mean gradient of 10 mm Hg across the valve, calculated from simultaneous RA and right ventricular pressures (average of 10 beats) [Figure 3]. [Table 1] shows the pressure in each chamber and the gradients on cardiac catheterization and on echocardiography. There was no obstructive atherosclerotic coronary artery disease. In light of above findings, she was advised for repeat double valve surgery.
Figure 1: Skiagram chest PA (a) and lateral (b) view show bioprosthetic tricuspid valve ring (red arrow).

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Figure 2: Transthoracic echocardiography: (a) Apical four-chamber view showing thickened bioprosthetic tricuspid leaflets, markedly dilated right atrium and enlarged left atrium, and (b) continuous wave Doppler across tricuspid bioprosthesis shows elevated gradients and time velocity integral of 86.6 cm (red arrow) (c) apical four-chamber view showing severe mitral regurgitation.

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Figure 3: Invasive hemodynamics using simultaneous right atrium and right ventricle pressures shows elevated gradients across tricuspid bioprosthesis (shaded area).

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Table 1: Pressure in all chambers and gradients on cardiac catheterization and on echocardiography

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  Discussion Top


TVR is less commonly encountered in clinical practice and is reserved for cases where tricuspid valve repair is not possible or has failed. The replacement of the tricuspid valve with bioprosthetic valve is performed due to the high durability in the tricuspid position and the benefit of discontinuation of the use of anticoagulant medication.[4],[5],[6] When this replaced valve is monitored over time, the bioprosthesis calcifies, thickens, and exhibits signs of degeneration such as regurgitation or stenosis. However, a low prevalence of TS is noted in patients with degenerated bioprosthesis than tricuspid regurgitation.[3] Although several cases of bioprosthetic tricuspid valve stenosis after TVR with bioprosthetic valves have been well-described in the literature,[1],[2],[3],[7] the clinical picture of bioprosthetic TS in complex Indian patients is rarely reported.

On account of the rarity of bioprosthetic tricuspid valve stenosis, it may be overlooked and leads to misdiagnosis. There are numerous issues such as acoustic shadowing from the sewing ring, lack of acquaintance with normal two-dimensional echocardiographic presentation of tricuspid prostheses, and difficulty imaging patients with substantial volume overload which causes misdiagnosis.[8] The long-term outcomes following TVR with bioprosthetic valve are typically dismay due to the progression of RHD, preoperative liver dysfunction, residual pulmonary hypertension, and reduced right ventricular ejection fraction.[7],[9],[10] In the present case, the time between the initial TVR and TS was more than 10 years, which was quite higher than the figures reported by Hirata et al.[3] This might be attributable to the late diagnosis of bioprosthetic tricuspid valve stenosis and underestimation of severity in our patient.

In the present case, elevated jugular venous pressure with slow y descent, mild leg edema, and diastolic rumble was the most important clinical manifestations, which were also noted by Hirata et al.[3] in their case series conducted on Japanese patients. Clinical examination revealed both severe bioprosthetic tricuspid valve stenosis and mild tricuspid regurgitation. This may be due to the thickening and calcification of leaflets' tips and the fixed semiopen position produced by the extensive fusion of the commissures. The existence of severe bioprosthetic tricuspid valve stenosis and severe MR in our patient was finally confirmed by two-dimensional echocardiography and cardiac catheterization.


  Conclusion Top


This instance illustrates a chronic RHD patient with diagnosed late bioprosthetic tricuspid valve stenosis after more than 10 years of TVR. It is critical to recognize the distinctive characteristics of bioprosthetic valve stenosis at an early stage in patients with RHD. In this case, the author emphasizes the importance of prompt and accurate diagnosis in clinical practice as a fraction of patients may experience rapid deterioration and may worsen clinical prognosis.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Laudari S, Tiwari KK, Adhayaru S, Subedi A. A rare case report on rheumatic origin of severe Tricuspid stenosis. J Natl Med Coll 2021;6:56-8.  Back to cited text no. 1
    
2.
Naser JA, Arghami A, Eleid MF, Pislaru SV. Severe tricuspid bioprosthetic valve stenosis as an unusual cause of pulmonary embolism: A case report. Eur Heart J Case Rep 2021;5:ytab169.  Back to cited text no. 2
    
3.
Hirata K, Tengan T, Wake M, Takahashi T, Ishimine T, Yasumoto H, et al. Bioprosthetic tricuspid valve stenosis: A case series. Eur Heart J Case Rep 2019;3:ytz110.  Back to cited text no. 3
    
4.
Vassileva CM, Shabosky J, Boley T, Markwell S, Hazelrigg S. Tricuspid valve surgery: The past 10 years from the Nationwide Inpatient Sample (NIS) database. J Thorac Cardiovasc Surg 2012;143:1043-9.  Back to cited text no. 4
    
5.
Said SM, Burkhart HM, Schaff HV, Johnson JN, Connolly HM, Dearani JA. When should a mechanical tricuspid valve replacement be considered? J Thorac Cardiovasc Surg 2014;148:603-8.  Back to cited text no. 5
    
6.
Anselmi A, Ruggieri VG, Harmouche M, Flécher E, Corbineau H, Langanay T, et al. Appraisal of long-term outcomes of tricuspid valve replacement in the current perspective. Ann Thorac Surg 2016;101:863-71.  Back to cited text no. 6
    
7.
Morimoto N, Matsushima S, Aoki M, Henmi S, Nishioka N, Murakami H, et al. Long-term results of bioprosthetic tricuspid valve replacement: An analysis of 25 years of experience. Gen Thorac Cardiovasc Surg 2013;61:133-8.  Back to cited text no. 7
    
8.
Zoghbi WA, Chambers JB, Dumesnil JG, Foster E, Gottdiener JS, Grayburn PA, et al. Recommendations for evaluation of prosthetic valves with echocardiography and Doppler ultrasound: A report From the American Society of Echocardiography's Guidelines and Standards Committee and the Task Force on Prosthetic Valves, developed in conjunction with the American College of Cardiology Cardiovascular Imaging Committee, Cardiac Imaging Committee of the American Heart Association, the European Association of Echocardiography, a registered branch of the European Society of Cardiology, the Japanese Society of Echocardiography and the Canadian Society of Echocardiography, endorsed by the American College of Cardiology Foundation, American Heart Association, European Association of Echocardiography, a registered branch of the European Society of Cardiology, the Japanese Society of Echocardiography, and Canadian Society of Echocardiography. J Am Soc Echocardiogr 2009;22:975-1014.  Back to cited text no. 8
    
9.
Filsoufi F, Anyanwu AC, Salzberg SP, Frankel T, Cohn LH, Adams DH. Long-term outcomes of tricuspid valve replacement in the current era. Ann Thorac Surg 2005;80:845-50.  Back to cited text no. 9
    
10.
Carrier M, Hébert Y, Pellerin M, Bouchard D, Perrault LP, Cartier R, et al. Tricuspid valve replacement: An analysis of 25 years of experience at a single center. Ann Thorac Surg 2003;75:47-50.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1]



 

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