Tricuspid Balloon Valve Fracture and Valve-in-Valve-in-Valve in a patient with Tetralogy of Fallot

Abstract Background Tetralogy of Fallot is the most common form of cyanotic congenital heart disease, with patients often requiring repeated valvular interventions throughout their lifetime. Transcatheter intervention play an important role in this cohort, and have been incorporated into guidelines for the management of prosthetic pulmonary valve degeneration, with growing observational data of transcatheter procedures in the tricuspid position. Here we describe a patient with Tetralogy of Fallot where transcatheter procedures were utilized in a patient of high surgical risk. Case presentation A 32 year old female with a history of repaired Tetralogy of Fallot presented with treatment resistant right sided heart failure. She had previously undergone four sternotomies, resulting in a 31mm Mosaic valve in the tricuspid position, and a 25mm homograft in the pulmonary position. She had also underwent a tricuspid valve in valve procedure for severe bioprosthetic valve stenosis, which had re-stenosed after 4 years. She was discussed in a multidisciplinary meeting, and given her multiple previous sternotomies and morbid obesity, decision was made to attempt further percutaneous intervention. She successfully underwent a Tricuspid Valve-in-Valve-in-Valve procedure with a 29mm Sapien 3 valve. Six month follow up demonstrated favourable valve hemodynamics, along with improvement in symptoms of right sided heart failure. Conclusions Transcatheter procedures have had an evolving role in the management of patients with congenital heart disease. This case highlights the utility of transcatheter interventions in a patient of very high surgical risk. Although the long term durability of these interventions are yet to be determined in the literature, they play an important role in prolonging the lifespan of a surgical valve, which in turn reduces the total sternotomies patients undergo over their lifetime.