A Case Report: Transcatheter Bicaval Valve Implantation in a CRT-D Patient With Severe Tricuspid Regurgitation and Transient Lead inconsistency

The human heart is a four-chambered pump, but it is also a complex plumbing system where blood flows in one direction, guided by one-way doors called valves. When these doors fail to close tightly, blood leaks backward, a condition known as regurgitation. This is particularly problematic on the right side of the heart, where the tricuspid valve sits. If this valve leaks severely, blood backs up into the veins that carry fluid from the rest of the body, causing swelling in the legs and abdomen and making it difficult to breathe. For decades, the only way to fix a broken tricuspid valve was open-heart surgery, a major operation that many elderly patients with other health issues simply cannot survive. In recent years, doctors have developed less invasive ways to repair these valves using catheters, or thin tubes, threaded through the veins. However, a new complication has emerged: many patients with severe heart failure already have electronic devices, like pacemakers or defibrillators, with wires running through their veins and into the heart. These wires can get in the way of new valve procedures, creating a difficult puzzle for medical teams to solve.

This case report tells the story of an 81-year-old man who faced this exact dilemma. He suffered from severe leakage of his tricuspid valve, which had left him so short of breath and swollen that he could barely move, a state doctors describe as the most severe level of heart failure. He also had a cardiac resynchronization therapy-defibrillator, a sophisticated device with wires placed in his heart to help it beat in sync and protect him from dangerous rhythms. Because of his age and other health conditions, surgeons told him he was too high-risk for traditional open-heart surgery. Instead, a team of specialists decided to try a newer, less invasive approach called transcatheter bicaval valve implantation. This procedure does not fix the leaking tricuspid valve itself. Instead, it places two new, self-expanding valves in the large veins above and below the heart—the superior and inferior vena cava. These new valves act as a dam, stopping the backward flow of blood from the heart into the veins, which relieves the pressure and swelling throughout the body.

The procedure was performed under general anesthesia using a large tube inserted through a vein in the groin. The team carefully guided the new valves into place using X-ray imaging and ultrasound. As they deployed the valve in the upper vein, a moment of concern arose. The movement of the delivery tool caused a slight, temporary shift in one of the wires from the man's existing heart device, which was positioned in a nearby vein. This shift caused a brief spike in the electrical signal needed to make the heart beat, a sign that the wire had moved slightly. However, the team did not panic. They immediately stopped, checked the device with specialized equipment, and confirmed that the wire was still working correctly and that the heart was still receiving the necessary electrical signals. No one needed to reposition the wire or perform any additional surgery. The team proceeded to place the second valve in the lower vein, completing the procedure.

In the weeks and months that followed, the results were striking. The man's breathing improved rapidly, and the swelling in his legs disappeared. Within a month, he had moved from being unable to perform any physical activity to being able to walk and function normally, a significant jump in his quality of life. The pressure in his veins, which had been dangerously high, dropped to a normal level. Over the next six months, he remained stable, requiring fewer medications to manage fluid and not needing to be hospitalized for heart failure. The wires from his heart device remained stable, and the new valves continued to function perfectly, effectively blocking the backward flow of blood.

This case demonstrates that it is possible to perform this complex valve procedure even in patients with intricate, pre-existing heart devices. While the interaction between the new valve and the old wires caused a brief, minor disturbance, the team's careful planning and immediate monitoring allowed them to navigate the issue without harm. The success of this operation relied heavily on the collaboration between different types of heart specialists, including those who manage heart structure and those who specialize in heart electronics. It suggests that for patients who are too frail for surgery, this approach offers a viable path to relief, provided that doctors carefully map out the anatomy beforehand and watch the electronic devices closely during the procedure. The story of this patient offers a hopeful example of how modern medicine can adapt to treat the most vulnerable and complex cases.