CASE REPORT Early leaflet thrombosis complicating transcatheter implantation of a Sapien 3 valve in a native right ventricular outflow tract Mounir Riahi, MD | Philipp Blanke, MD | John Webb, MD | Ronald G. Carere, MD Division of Cardiology, St. Paul’s Hospital, Vancouver, British Columbia, Canada Correspondence Ronald G. Carere, MD, St Paul’s Hospital, 479B - 1081 Burrard Street, Vancouver, British Columbia V6Z 1Y6, Canada. Email: rcarere@providencehealth.bc.ca A 59-year-old female with Tetralogy of Fallot had a previous complete repair with RVOT patch enlargement. She developed subsequent severe symptomatic (NYHA III) pulmonary regurgitation with severe RV dilatation. She had a concomitant interstitial lung disease secondary to hypersensi- tivity pneumonitis that precluded her from cardiac surgery. After preprocedural assessment using computed tomography, echocardiography and invasive angiography we decided to implant a 29 mm Edwards Sapien 3 valve without pre-stenting. The Sapien 3 valve was implanted in a satis- factory position using rapid RV pacing. The valve appeared well expanded with good circularity on fluoroscopy. A transthoracic echocardiography on the following day showed no pulmonary regur- gitation with a peak gradient of 14 mmHg across the prosthesis. At 4 weeks follow-up, the patient felt a marked improvement (NYHA II) but a CT scan showed bileaflet valve thickening with pre- served stent expansion. A concomitant echo-doppler showed a significant increase of peak pulmonary gradient to 26 mmHg. After a six weeks course of warfarin therapy, the transpulmo- nary valve peak gradient came down to 16 mmHg and leaflet thickening resolved on CT. The Sapien 3 system helped achieve a successful transfemoral percutaneous pulmonary valve implantation in a challenging native RVOT anatomy. This case was complicated by early valve thrombosis as documented by CT and was successfully treated with oral anticoagulation. KEYWORDS adult congenital heart disease, computed tomography, tetralogy of fallot 1 | INTRODUCTION Thrombotic leaflet thickening has been reported in both surgical and transcatheter aortic valve prosthesis [1]. This phenomenon is typically subclinical but can be associated with an alteration of the hemody- namic profile of the implanted valve. We aim to report the first observed case following percutaneous pulmonary valve implantation (PPVI). 2 | CASE REPORT A 59-year-old woman with tetralogy of Fallot had a complete surgical correction consisting of transannular patch enlargement and ventricular septal defect closure at 5 years of age. She presented with severe symp- tomatic (NYHA functional class III) pulmonary regurgitation. She also had chronic hypersensitivity pneumonitis with severe restrictive lung disease (diffusing lung capacity of 45% and functional volume capacity 68% of predicted). Further workup with cardiac magnetic resonance confirmed a severely dilated right ventricle (RV; 151 ml/m2). On contrast-enhanced cardiac CT, the right ventricular outflow tract (RVOT) measured 15.7 mm by 20.4 mm at the level of the main pulmonary artery. The patient was assessed by a multi-disciplinary team and was judged to be at prohibitively high risk for surgery but suitable for a PPVI. The procedure was performed under general anesthesia with fluo- roscopic guidance. The patient was pre-medicated with aspirin, clopi- dogrel, and cefazoline. A loading dose of 80 Units/Kg of intravenous heparin was administered after sheath insertion. Before valve implanta- tion we inflated a 34 mm Amplatzer sizing balloon with simultaneous aortic root injection to ensure that there were no signs of coronary obstruction. We did not rely on the sizing balloon dimensions to choose the valve size. This is because the RVOT appeared relatively small and distensible owing to a low calcification burden. We thought that a significantly oversized Sapien 3 valve would be able to expand adequately with sufficient anchoring without the need of prestenting. A 29 mm Sapien-3 transcatheter heart valve (Edwards Life- sciences, Irvine, USA) was successfully implanted under rapid Catheter Cardiovasc Interv. 2017;1–5. wileyonlinelibrary.com/journal/ccd V C 2017 Wiley Periodicals, Inc. | 1 Received: 7 April 2017 | Revised: 17 May 2017 | Accepted: 8 June 2017 DOI: 10.1002/ccd.27183