The new heart valve was ready. The problem was getting it deep enough into the heart.
Cardiologists in Germany tried one standard maneuver after another during a catheter-based tricuspid valve replacement, and none worked. Finally, they reached for a tool usually used to retrieve lost hardware: a snare catheter with a wire loop. They looped it around the valve's delivery system and steered it into position.
The team titled its report "Lucky Luke in the Cath lab?" as a nod to the gunslinging cowboy of Belgian comic fame. The case was published May 14 in European Heart Journal - Case Reports by cardiologists at the Heart and Diabetes Center North Rhine-Westphalia in Bad Oeynhausen.
A Leaky Valve in a Crowded Heart
The patient, a 75-year-old man, had dilated cardiomyopathy, atrial fibrillation, and an implanted cardiac resynchronization defibrillator. Between 2020 and 2024, his tricuspid valve, which separates the heart's two right-sided chambers, went from mildly to severely leaky, a condition called tricuspid regurgitation.
Despite the maximum tolerated dose of diuretics and optimal medications, he became short of breath during even light activity and had severe leg swelling and fluid in his abdomen.
His options were limited. Surgery was considered too risky, and a clip-based repair was unfavorable because his valve leaflets had a gap of about 9 by 13 millimeters. One of his device leads also pressed against a valve leaflet. After a heart team review, and because he opposed surgery, doctors planned a transcatheter replacement using a 56-millimeter Evoque valve.
The FDA approved Evoque on Feb. 1, 2024. Its maker, Edwards Lifesciences, announced it as the first transcatheter therapy approved in the U.S. for tricuspid regurgitation. The FDA describes a cow-tissue valve on a self-expanding nickel-titanium frame, compressed onto a catheter and threaded through the femoral vein in the groin.
In the clinical study summarized by the FDA, which compared 96 patients treated with the valve plus medicine against 54 treated with medicine alone, about 99% of valve patients had their severe leakage reduced to moderate or less, compared with about 22% of those on medicine alone. About 28% of valve patients also had a major safety complication, such as heart-related death, a new permanent pacemaker, or severe bleeding, within 30 days.
One Failed Maneuver After Another
Under general anesthesia, the team entered through the right femoral vein. Despite multiple maneuvers, they could not orient the delivery system toward the center of the valve.
They switched to the left femoral vein and achieved central alignment, but they could not push the system deep enough into the right ventricle for proper implantation. They then inflated a 20-millimeter balloon in the upper inferior vena cava, the large vein leading into the heart, hoping to deflect the delivery sheath toward the ventricle. That did not work either.
The authors had flagged the problem in general terms. Computed tomography scans can size a valve well, they wrote, but vein anatomy and the angle where the inferior vena cava joins the heart can still complicate a procedure. They called device delivery the "elephant in the room" for this kind of valve replacement.
Borrowing a Retrieval Tool for a New Job
The fix came from a different corner of interventional cardiology. Through the right femoral vein, the team advanced a 20-millimeter GooseNeck snare and a steerable sheath and positioned them behind the valve delivery system.
They snared the delivery system's shaft just above the valve, used X-ray and ultrasound imaging to make sure the loop was not tangled with the defibrillator lead, and then used the steerable sheath to guide the whole assembly deeper into the right ventricle. The valve was deployed in stages.
Immediate imaging showed minimal remaining leakage through the valve and only a trivial leak around its edge. The patient had no complications at the vein access sites. At one month, he reported less breathlessness and swelling on a moderate diuretic dose, and ultrasound showed trivial residual leakage.
Snares are traditionally used to retrieve dislodged stents, guidewires, or leadless pacemakers, and more recently to manage complications such as valve migration. Here, the authors noted, the snare was used proactively to place the valve at the right depth in the first place, avoiding the need to reposition it after release.
A Clever Workaround, Not Yet a Standard
The technique was off-label, and this is a single case from an experienced center. The report does not show how often it would work or what risks it might add in other patients. Other strategies, including a transjugular approach through the neck, have also been proposed for difficult anatomy.
Two authors disclosed ties to Edwards Lifesciences: one received consulting fees, and the other is a consultant who has received speaker honoraria from the company.
Still, the authors argued that sharing unconventional but effective techniques could expand the safety and reach of transcatheter tricuspid valve replacement in patients with complex anatomy. Many of those patients are older, carry device leads, or have enlarged hearts, the kind of anatomy that complicates this procedure.
For patients with severe tricuspid regurgitation, the case offers no new treatment decision. It is best read as a look inside the cath lab, where success sometimes depends on improvisation.
Key Questions Answered
What is tricuspid regurgitation?
It is a leak in the tricuspid valve that lets blood flow backward from the right ventricle into the right atrium. Severe cases can cause breathlessness, fatigue, leg swelling, and abdominal fluid buildup.
What went wrong during this procedure?
The team could not position the valve delivery system deep enough in the heart despite several standard maneuvers, including switching access veins and using a balloon to deflect the sheath.
How did the snare help?
Doctors looped a wire snare around the delivery system's shaft and used a steerable sheath to guide it deeper into the right ventricle, allowing the valve to be deployed at the correct depth.
How did the patient do?
Imaging showed minimal remaining leakage. At one month, he had less shortness of breath and swelling, and his residual leakage was trivial.
Is this technique now standard practice?
No. It was an off-label workaround in one patient. Its broader safety and effectiveness have not been studied.
