Acute Hemodynamic Instability After Transcatheter Tricuspid Valve Replacement

We describe a series of 3 patients presenting with acute hemodynamic instability (AHI) after transcatheter tricuspid valve replacement (TTVR). The first case illustrates abrupt right ventricular-pulmonary artery uncoupling due to the marked increase in afterload that stereotypically occurs after acute reduction of tricuspid regurgitation. The second case illustrates AHI after myocardial ischemia triggered by TTVR in a patient with infiltrative cardiomyopathy. The third case highlights AHI as a consequence of marked vasoplegia precipitated by a robust, unregulated inflammatory response after TTVR. Although AHI after TTVR is infrequent, the condition is highly morbid, and prompt recognition of the underlying cause is essential to stabilize the patient and facilitate recovery. We also illustrate the potential for using a cardiac simulator to predict the hemodynamic consequences of TTVR. Development of novel predictive tools and familiarity with the clinical patterns of AHI after TTVR will become increasingly important as TTVR becomes more common.