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A 75-year-old woman presented with progressive dyspnea and peripheral edema. Her history
included atrial fibrillation, mechanical mitral prosthesis, dual-chamber pacemaker,
and chronic kidney disease. Echocardiography revealed severe functional tricuspid
regurgitation, originating from the posteroseptal commissure, with mild right ventricular
dysfunction (Fig. 1A). After heart team review, the patient was deemed inoperable and unsuitable for
transcatheter edge-to-edge repair or annuloplasty because of anticipated mechanical
interference of the pacemaker lead. Heterotopic caval valve implantation (CAVI) with
TricValve (Products + Features GmbH, Vienna, Austria) was planned.
Figure 1(A) Baseline echocardiography showing massive tricuspid regurgitation. (B) Two-dimensional/3-D transesophageal echocardiography showing noncoaptation of the
inferior vena cava leaflets (red arrowheads) due to pacemaker lead (white arrowheads) interference. (C) Fluoroscopic loop-shaped lead after caval valve implantation. (D, E) Percutaneous lead capture and partial externalization around the device. (F-H) Three-dimensional computed tomography modelling illustrating the acute bend (asterisk) of the pacemaker lead before (F) and after (G) and (H) balloon-expandable valve implantation. (I, J) Valve-in-valve implantation within the inferior vena cava valve, without residual
leak. (K) Coaptation restoration after SAPIEN valve (Edwards Lifesciences, Irvine, CA) implantation.
