Catheterization and Cardiovascular Diagnosis zyx 28:142-148 (1993) Percutaneous Double Balloon Valvuloplasty for Stenosis of Porcine Bioprostheses in the Tricuspid Valve Position: A Report of 2 Cases Michel S. Slama, MD, Luc H. Drieu, MD, Marie-Christine Malergue, MD, Alain Dibie, MD, Jacques Temkine, MD, Claude Sebag, MD, Yves Lecompte, MD, Franqois Laborde, MD, and Gilbert Motte, MD The feasibility and results of percutaneous double balloon valvuloplasty were evaluated in 2 patients with stenosis of porcine bioprostheses in the tricuspid valve position. The procedures were performed with a Trefoil 3 x 10 and a 15 mm balloon. Long inflations (4 and zyxwvutsrqp 3 minutes) were well tolerated. A significant immediate increase in the valve area, without significant valvular regurgitation, was achieved in both cases, from 0,65 to 1,15 cm2in case 1 and from 0,9 to 1,65 cm2in case 2. Both patients requiredvalve replacement during the follow-up, at 14 and 21 months. There was no restenosis, but echocardio- graphy showed right atrial thrombosis in case 1. Progressive restenosis with peripheral edema and increase of the mean doppler gradient occurred in case 2. The procedure is feasible, safe, and well tolerated. It provides significant immediate hemodynamic improvement, but it should be considered as a palliative technique since a normal valve area can not usually be obtained and a restenosis is likely to occur at midterm follow-up. Key words: bioprosthesis, percutaneous valvuloplasty, double balloon technique zyx o 1993 Wiley-Liss, Inc. INTRODUCTION zyxwvutsrq Long-term follow-up of patients with porcine biopros- theses has shown that an intrinsic tissue failure (valve stenosis or incompetence, perforation, cuspal tears, fi- brous stiffening of the leaflets, calcium deposits) is re- sponsible for two-thirds of valve failures and may occur in 25% of cases after 10 years. Degeneration seems less frequent in the tricuspid valve position and is mainly due to fibrous tissue overgrowth. A stenosis in a bioprosthe- sis in the tricuspid position leads to reoperation most of the time. Percutaneous balloon valvuloplasty has been proposed for the treatment of some of these patients. We report 2 more cases treated with the double balloon tech- nique. CASE I A 38-year-old woman was regularly followed since 1980, when she had tricuspid valve replacement with a N" 33 Carpentier Edwards porcine bioprosthesis for in- fective endocarditis (Staphylococcus Aureus) due to in- travenous opiate injection. A diastolic rumble was first perceived in 1987 while she was asymptomatic. In Jan- uary 1989, she complained of hepatic pain during exer- tion. Physical examination revealed jugular veinous dis- zyxwvu 0 1993 Wiley-Liss, Inc. tension and a 3/6 diastolic rumble that increased with inspiration, consistent with tricuspid valve stenosis. Chest X-ray and ECG were normal. Two-dimensional echocardiogram (2DE) showed isolated right atrial en- largement and bioprosthesis leaflets thickening with re- duced motion. The other valves and the left ventricle were normal. Color flow Doppler study showed a narrow high velocity jet through the bioprosthesis with minimal regurgitation; the mean gradient was 8 mmHg and the tricuspid valve area was 0.6 cm2 by pressure halftime (Fig. 1). Cardiac catheterization was performed after oral premedication (diazepam 10 mg) under local anesthesia. The patient had given informed consent for percuta- neous valvuloplasty, and the surgical team was readily available. Vascular access was obtained with a 6F arte- rial sheath in the left groin, and 8F sheaths in both fem- oral veins. Two 7F floatation catheters (Critikon) were From the Service de Cardiologie, HBpital Antoine Beclere, Clamart, and Centre Medico Chirurgical de la Porte de Choisy, Paris, France Received April 19, 1992; revision accepted August 12, 1992. Address reprints request to Michel S. Slama, Service de Cardiologie, HBpital Antoine BCclkre, 157, avenue de la Porte de Trivaux, 92141 Clamart, France.