https://orcid.org/0000-0003-0673-4876
A 52-year-old man underwent heart transplantation due to end stage cardiac sarcoidosis, with uncomplicated post-operative course. One month post-operatively, he developed supraventricular tachycardia (SVT) after the return of a scheduled right ventricular (RV) endomyocardial biopsy (EMB) as part of routine rejection screening. Transthoracic echocardiogram (TTE) showed severe tricuspid regurgitation (TR) with dilated inferior vena cava and systolic flow reversal in the hepatic veins (Panels A and B, Supplementary data online, Video S1) of unclear mechanism. Transoesophageal echocardiogram (TOE) showed severe TR due to flail leaflet presumably caused by EMB (Panels C and D, Supplementary data online, Videos S2 and S3). The tricuspid valve was repaired with Goretex artificial cord ×2 and 28 mm Cosgrove annuloplasty ring with excellent final result and uncomplicated post-operative course. Two weeks later, due to recurrent SVT and volume overload, the patient underwent TTE that showed significant TR of unclear mechanism (Panel E, Supplementary data online, Video S4). Subsequent TOE showed dehisced tricuspid annuloplasty ring from the lateral tricuspid annulus associated with severe tricuspid regurgitation (Panels F–I, Supplementary data online, Videos S5 and S6). This may have resulted from spontaneous post-operative dehiscence or additional EMB that the patient underwent following initial valve repair. Ultimately, the patient underwent 33-mm Epic bioprosthetic tricuspid valve replacement with excellent result. Since the valve replacement, biopsies were avoided and rejection screening has been performed via Gene Expression Profiling (AlloMap) for the past 7 months, with no evidence of rejection. Serial TTEs have been consistent with excellent graft function and no TR. (Panel A) TTE with colour comparison four-chamber view illustrating tricuspid regurgitation. LA, left atrium; LV, left ventricle; RA, right atrium; RV, right ventricle. (Panel B) TTE pulse wave Doppler of the inferior vena cava/hepatic veins showing systolic flow reversal. (Panel C) TOE (trans-gastric view) illustrating torn tricuspid chordae prolapsing into the RA (arrow). RA, right atrium; RV, right ventricle. (Panel D) TOE with colour Doppler trans-gastric view illustrating significant tricuspid regurgitation. (Panel E) TTE with colour comparison four-chamber view illustrating tricuspid regurgitation. LA, left atrium LV, left ventricle; RA, right atrium; RV, right ventricle. (Panel F) TOE (mid-oesophageal 4 chamber view) illustrating the detached annuloplasty ring (arrow) from the lateral tricuspid annulus. LA, left atrium LV, left ventricle; RA, right atrium; RV, right ventricle. (Panel G) TOE colour Doppler mid-oesophageal four-chamber view illustrating tricuspid regurgitation. LA, left atrium LV, left ventricle; RA, right atrium; RV, right ventricle. (Panel H) TOE (mid-oesophageal biplane modified bi-caval view illustrating the detached annuloplasty ring (arrow) from the tricuspid annulus. SVC, superior vena cava; RA, right atrium, LA, left atrium, RV, right ventricle. (Panel I) TOE (3D mid-oesophageal view) illustrating the detached annuloplasty ring (arrow) from the lateral tricuspid annulus. IAS, intra-atrial septum; LA, left atrium.
Supplementary data are available at European Heart Journal - Cardiovascular Imaging online.
The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate.
Author notes
Abra Guo and Hilmi Alnsasra authors contributed equally to this work.
