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Percutaneous valve-in-valve implantations: importance of knowing the effective internal diameter of bioprosthetic valves
  1. A B Gopalamurugan,
  2. Markus Reinthaler,
  3. Michael J Mullen
  1. Department for Structural Interventions, The Heart Hospital, University College London Hospitals NHS Trust, London, UK
  1. Correspondence to A B Gopalamurugan, Department for Structural Interventions, The Heart Hospital, 16-18 Westmoreland Street, London W1M 8PH, UK; gopalamurugan{at}

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Valve-in-valve (VIV) implantation with the transcatheter aortic valve implantation (TAVI) technology has been used to treat dysfunctional bioprosthetic valves. A factor that determines a patient's suitability is the valve size of the previously implanted bioprosthetic valve. A 64-year-old lady with previous tricuspid valve replacement (33 mm stented tissue valve, model: ESP100-33M-00 Epic, St Jude Medical, Minnesota, USA), was referred for treatment of her dysfunctional tricuspid valve due to severe tricuspid regurgitation. She had a cardiac resynchronisation therapy device implanted where the ICD lead was placed outside the bioprosthetic valve during her previous tricuspid valve surgery. Her calculated Euroscore II was 37%. A percutaneous tricuspid VIV implantation was proposed. As per the product literature, the internal diameter of her 33 mm bioprosthetic valve was 31 mm (figure 1), so we were reluctant to consider a VIV implantation as the largest commercially available valve technology was a 29 mm (Sapien XT, Edwards Lifesciences, Irvine, Calif) valve used for TAVI. Before declaring the patient's unsuitability, we investigated the valve dimensions in vitro with a new 33 mm Epic valve. This revealed an effective internal diameter measured by a calibrated digital vernier calliper at several measuring planes to be no more than 28 mm (figure 2). We therefore proceeded to perform a percutaneous tricuspid VIV implantation with a 29 mm TAVI prosthesis (Sapien XT, Edwards Lifesciences, Irvine, Calif) through the right internal jugular vein approach. This resulted in a successful procedure with normal postimplantation valve function (figure 3, see online supplementary video 1). This case demonstrates the importance of assessing the effective internal diameter of bioprosthetic valves accurately before deciding on patient suitability for VIV implantations.

Figure 1

Product literature showing Epic valve dimensions.

Figure 2

In vitro measurements of a 33 mm Epic valve at various planes.

Figure 3

Transjugular tricuspid valve-in-valve implantation.

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  • Contributors All the authors in this article contributed on the following: (1) conception and design, or analysis and interpretation of data, drafting the article, or revising it critically for important intellectual content; (2) final approval of the version to be published.

  • Competing interests None.

  • Provenance and peer review Not commissioned; internally peer reviewed.

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