Mechanical tricuspid balloon ‘valvuloplasty’ in a prohibitive risk patient with cardiogenic shock: a case report

Background We present a complex case of a failing tricuspid mechanical valve prosthesis in a patient with refractory cardiogenic shock at prohibitive risk for surgery in whom balloon 'valvuloplasty' resulted in immediate haemodynamic improvement in valve function. Case summary A 67-year-old woman with remote history of endocarditis s/p tricuspid valve repair and mechanical aortic valve replacement was referred for second opinion and management of new severe symptomatic tricuspid valve stenosis resulting in progressive debilitating congestive heart failure (HF). The patient was approved by the heart team to undergo redo open heart for surgical repair of the tricuspid valve. Intraoperative technical challenges were met to repair the tricuspid valve. In turn, the native valve was resected and a 33 mm On-X mechanical valve prosthesis. The patient's post-operative course was complicated by recurrent haemoptysis, prolonged mechanical respiratory support, acute kidney injury, and cardiogenic shock. Surgical re-exploration to address the dysfunctional mechanical tricuspid valve was felt to be prohibitive. Structural heart team was consulted. Cardiac catheterization was recommended to ascertain and confirm findings. The patient was transferred to the cardiac catheterization laboratory. Initial fluoroscopic examination of the heart confirmed the echocardiographic results of an immobile septal leaflet of the recently implanted mechanical tricuspid valve. An 8 × 40 mm Mustang OTW angioplasty balloon was then advanced across the mechanical valve and inflated gradually at nominal pressure. A single inflation resulted in successful restoration of valve leaflet function. Discussion To the best of our knowledge, this is the first balloon 'valvuloplasty' on a mechanical On-X valve in the tricuspid position.