Defying Limits: Fluoroscopy-Only Transcatheter Tricuspid Valve-in-Valve for Severe Bioprosthetic Stenosis in a Complex Case of Cirrhosis: A Case Report

Background Severe tricuspid stenosis (TS) is a rare but serious condition that can lead to right heart failure and hepatic congestion. In some cases, it may be misdiagnosed as cardiac cirrhosis, leading to inappropriate treatment. In high-risk patients, transcatheter tricuspid valve-in-valve implantation (TTVIV) is considered a less invasive alternative to surgery. This procedure typically requires advanced imaging; however, in this report, TTVIV was successfully performed using only fluoroscopy. Case Presentation A 70-year-old woman with a history of rheumatic heart disease presented with severe right heart failure symptoms. She had previously undergone aortic and mitral valve replacement with mechanical prostheses, followed by tricuspid valve replacement with a Carpentier-Edwards bioprosthetic valve due to progressive tricuspid regurgitation. Echocardiography findings showed severe tricuspid stenosis with a mean gradient of 8 mmHg and moderate right ventricular dysfunction. Given the patient's condition and imaging limitations, a decision was made to proceed with TTVIV guided solely by fluoroscopy. The procedure was successfully performed, and immediately post-implantation, the tricuspid gradient decreased to 3 mmHg. During one-year follow-up, the patient showed significant improvement in symptoms, including reduced edema, ascites, and improved cardiac and hepatic function. Conclusions This case demonstrates that TTVIV can be safely and effectively performed in patients with a bioprosthetic tricuspid valve when the stent frame is clearly visible on fluoroscopy, eliminating the need for advanced imaging. This approach may serve as a valuable alternative for high-risk patients.