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

Defying Limits: Fluoroscopy-Only Transcatheter Tricuspid Valve-in-Valve for Severe Bioprosthetic Stenosis in a Complex Case of Cirrhosis: A Case Report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Defying Limits: Fluoroscopy-Only Transcatheter Tricuspid Valve-in-Valve for Severe Bioprosthetic Stenosis in a Complex Case of Cirrhosis: A Case Report Ayoub Salehi, Ata Firouzi, Ezzat Rezai monfared This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6310439/v1 This work is licensed under a CC BY 4.0 License Status: Under Revision Version 1 posted 10 You are reading this latest preprint version Abstract 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. Tricuspid stenosis transcatheter Valve-in-valve Fluoroscopy-guided intervention Tricuspid Bioprosthetic Case Report Figures Figure 1 Figure 2 Figure 3 Introduction Severe tricuspid stenosis (TS) is a rare but significant condition that primarily affects the right side of the heart. It is often associated with rheumatic heart disease and can lead to right heart failure, characterized by ascites, edema, and symptoms of hepatic congestion. When TS becomes advanced, it may present with signs similar to cardiac cirrhosis, making diagnosis and management challenging. The misdiagnosis of TS as hepatic disease may result in inappropriate treatments, such as the use of corticosteroids like prednisolone, which can further exacerbate the condition.[1] [2] For patients with severe TS, especially those with comorbidities such as cirrhosis and high surgical risk, transcatheter valve-in-valve implantation (TTVIV) offers a promising alternative to traditional surgery. TTVIV is an emerging technique that allows the implantation of a new valve within an existing prosthetic valve. This less invasive procedure is particularly beneficial for patients who are not suitable candidates for open-heart surgery. However, advanced imaging techniques such as CT angiography or intracardiac echocardiography (ICE) are usually required for optimal procedural guidance. In certain cases, such as with clear visualization of the valve stent frame in fluoroscopy, TTVIV can be successfully performed without these advanced imaging modalities.[3] This case report explores the successful use of TTVIV in a patient with severe TS misdiagnosed as cardiac cirrhosis, highlighting the potential of TTVIV as an effective treatment option even in resource-limited settings. Case Presentation A 70-year-old woman with a history of rheumatic heart disease presented to the hospital with severe symptoms of right heart failure. Her medical history includes aortic and mitral valve replacement with Björk-Shiley mechanical prostheses. 15 years ago, she underwent tricuspid valve repair, and three years later, due to progressive tricuspid regurgitation, she underwent tricuspid valve replacement with a Carpentier-Edwards bioprosthetic valve. This patient was mistakenly diagnosed with Rheumatic Cirrhosis and had been treated with prednisolone for several months. However, she developed worsening heart failure symptoms and presented with ascites, lower limb edema, jugular venous distension (JVD), dyspnea, and fatigue. Additionally, the patient exhibited jaundice in both skin and sclera, which correlated with cardiac cirrhosis. Further investigation revealed that the true cause of her symptoms was severe tricuspid stenosis (TS), rather than primary liver disease.And the cause of the patient's hepatic congestion was due to right-sided heart failure and tricuspid stenosis (TS). On echocardiography, the patient demonstrated severe tricuspid stenosis with a mean gradient (MG) of 8 mmHg, a peak tricuspid pressure half-time (PTH) of 200 ms, and a pulmonary artery pressure (PAP) of 40 mmHg. The inferior vena cava (IVC) was dilated with less than 50% respiratory variation, indicating elevated right atrial pressures. Both the right atrium (RA) and right ventricle (RV) were significantly enlarged, and RV function was moderately impaired. the patient had a preserved ejection fraction (EF) of 50%. Additionally, on angiography, moderate stenosis was observed in the mid part of the left anterior descending (LAD) artery, which was managed with medical follow-up. Due to the high surgical risk, which included the patient's history of cirrhosis, transcatheter tricuspid valve implantation (TTVIV) was selected as the appropriate therapeutic option. The procedure was successfully performed using fluoroscopy as the primary imaging tool, without the need for advanced imaging techniques. The procedure was performed according to the following steps: The MyVal prosthesis, 29mm in size, was selected based on the annular measurements of the tricuspid valve obtained via transesophageal echocardiography (TEE). The decision for this size was made carefully, considering the annulus size and the patient's anatomy. The True Balloon size was used with caution during the procedure to ensure proper inflation and positioning of the prosthesis. Additionally, no CT angiography was required for this patient, as adequate imaging was available through TEE. Access and Sheath Insertion: 1.The patient was sedated under conscious sedation, ensuring that they remained stable and comfortable during the procedure. 2. The right femoral vein was accessed for catheter insertion. 3. A 14F Python sheath was introduced over a stiff wire into the inferior vena cava (IVC). This sheath provided stable access for further catheter manipulations. 4. The Agilis NxT steerable introducer was then advanced into the right atrium (RA), providing flexibility and control for the subsequent guidewire advancement. Guidewire Passage and Catheter Navigation: 1. Using the A1 catheter and a hydrophilic wire, the catheter was passed through the bioprosthetic tricuspid valve. This allowed for precise guidance toward the left pulmonary artery (LPA). 2. A Lunderquist wire was placed in the LPA to provide a stable and secure pathway for the subsequent steps and to facilitate further catheter navigation. Prosthesis Delivery and Positioning: 1. The 29mm MyVal prosthesis was mounted onto the delivery catheter in an antegrade fashion, ensuring the proper alignment of the valve prior to insertion. 2. The delivery system was introduced carefully, ensuring the MyVal logo was facing downward. The catheter was flexed appropriately to direct the valve to the desired location. 3.The central marker of the MyVal prosthesis was positioned 3 to 5 mm below the base (ventricular side) of the surgical valve stent frame (Carpentier-Edwards bioprosthesis). This was crucial for proper valve function and avoiding any mechanical interference between the prosthesis and the bioprosthetic valve.(Figure 1) 4. Slow and controlled inflation of the MyVal valve was performed. The catheter was carefully adjusted to ensure coaxiality, providing optimal positioning and preventing any malpositioning of the valve. This allowed for accurate valve placement without the need for pacing. (Figure 2a and 2b) Final Valve Positioning: 1. The MyVal prosthesis was deployed, and its stent frame was visible. The central marker of the valve was positioned below the bioprosthetic valve annulus, ensuring proper valve seating and function. (Figure 3) 2. Due to the success of the procedure and the proper positioning of the valve, TEE was not required to confirm valve placement. 3.Post-procedural evaluation was carried out using transthoracic echocardiography (TTE). The valve was functioning properly, and no immediate complications were observed . During the procedure, the mean gradient of the bioprosthetic tricuspid valve was successfully reduced from 8 mmHg to 3 mmHg. The patient’s right atrial pressure was well-managed throughout the procedure, and there were no complications related to the procedure itself. Intraoperative hemodynamics showed improvement, and post-procedure, the patient remained stable. At the 1-month, 6-month, and 1-year follow-ups, the patient remained asymptomatic, with significant resolution of edema and ascites. Echocardiography revealed a well-functioning tricuspid valve prosthesis, and right ventricular function showed improvement. The patient continued to report good quality of life, with no signs of heart failure recurrence. Discussion Severe tricuspid valve stenosis (TS) is a rare but significant condition, often associated with rheumatic heart disease. Our patient, a 70-year-old woman, presented with severe TS, right heart failure, and liver cirrhosis. In such cases, treatment is challenging, as traditional surgical interventions carry high risks due to the patient's age and comorbidities. [ 5 ][ 7 ] In this case, the decision to proceed with transcatheter tricuspid valve-in-valve implantation (TTViV) was based on the patient's persistent symptoms despite medical therapy, including diuretics and steroids for cirrhosis, and her worsening clinical status. TTViV is an emerging approach for managing severe TS, particularly in patients who are not ideal candidates for conventional surgery. The MyVal prosthesis was selected for this patient due to its favorable clinical outcomes and compatibility with the patient's anatomical and functional requirements.[ 7 ] Several studies have demonstrated that TTViV is a feasible treatment for severe TS, especially in patients with deteriorating bioprosthetic valves. [ 7 ] Unlike conventional surgery, TTViV eliminates the need for sternotomy and allows for a faster recovery in patients like ours.[ 4 ] Furthermore, this procedure significantly reduced the mean transvalvular gradient from 8 mmHg to 3 mmHg, indicating improved hemodynamics and symptomatic relief. Key benefits of this intervention included a reduction in right atrial pressure, resolution of edema and ascites, and an overall improvement in the patient's quality of life. Follow-up echocardiography confirmed optimal valve function, with no complications observed, further supporting the safety and efficacy of TTViV in selected patients with severe TS.[ 8 ] The role of imaging in guiding these procedures is crucial. In this case, transesophageal echocardiography (TEE) played a key role in valve selection, annular sizing, and intra-procedural positioning. Although CT angiography was not required for this patient, TEE provided sufficient imaging guidance, eliminating the need for additional modalities. In high-risk patients, TEE serves as an excellent alternative for pre-procedural planning and procedural guidance.[ 8 ] Another important finding was the improvement in right ventricular function following the procedure. Tricuspid stenosis and regurgitation can impair right ventricular performance, which, if left untreated, may lead to progressive heart failure. Successful TS treatment in this patient prevented further cardiac deterioration and significantly enhanced her quality of life. Conclusion Transcatheter tricuspid valve-in-valve implantation (TTViV) is a safe and effective treatment option for patients with severe tricuspid valve stenosis (TS) who are at high surgical risk. This case demonstrates the feasibility of TTViV in restoring tricuspid valve function, reducing right atrial pressure, and significantly improving the patient’s symptoms and quality of life. The successful implantation of the MyVal prosthesis resulted in a marked reduction in the transvalvular gradient, resolution of edema and ascites, and improved right ventricular function. Follow-up echocardiography confirmed optimal prosthetic valve performance with no complications. As the field of structural heart interventions continues to evolve, TTViV offers a promising alternative to surgery for selected high-risk patients. Careful patient selection, precise procedural execution, and close follow-up are essential to achieving favorable outcomes. This case reinforces the growing role of transcatheter therapies in the management of complex valvular heart diseases. Abbreviations 1. TS Tricuspid Stenosis 2. TTVIV Transcatheter Tricuspid Valve-in-Valve Implantation 3. TEE Transesophageal Echocardiography 4. PTH Pressure Half-Time 5. PAP Pulmonary Artery Pressure 6. IVC Inferior Vena Cava 7. RA Right Atrium 8. RV Right Ventricle 9. LAD Left Anterior Descending 10. JVD Jugular Venous Distension 11. CT Computed Tomography 12. ICE Intracardiac Echocardiography Declarations Consent for publication: Written informed consent was obtained from the patient for the publication of this case report and any accompanying images. Funding: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. References Rodriguez Ziccardi, M., Pendela, V. S., & Singhal, M. (2023). Cardiac Cirrhosis. In StatPearls [Internet]. StatPearls Publishing. Last update: April 24, 2023. Available from: https://www.ncbi.nlm.nih.gov/books/NBK431053/ Golamari, R., Shams, P., Alahmadi, M. H., & Bhattacharya, P. T. (2024). Tricuspid Stenosis. In StatPearls [Internet]. StatPearls Publishing. Last update: June 22, 2024. Chen, S., Dershowitz, L., & George, I. (2021). Transcatheter valve implantation for degenerated tricuspid bioprosthesis and failed tricuspid ring. Texas Heart Institute Journal, 10(5). Jeganathan, R., Armstrong, S., Al-Alao, B., & David, T. (2013). The risk and outcomes of reoperative tricuspid valve surgery. Annals of Thoracic Surgery, 95(1), 119-124. https://doi.org/10.1016/j.athoracsur.2012.08.058 Nakano, K., Eishi, K., Kosakai, Y., Isobe, F., Sasako, Y., Nagata, S., Ueda, H., Kito, Y., & Kawashima, Y. (1996). Ten-year experience with the Carpentier-Edwards pericardial xenograft in the tricuspid position. Journal of Thoracic and Cardiovascular Surgery, 111(4), 605–612. https://doi.org/10.1016/S0022-5223(96)70312-4 Hirata, K., Tengan, T., Wake, M., Takahashi, T., Ishimine, T., Yasumoto, H., Nakasu, A., Mototake, H. (2019). Bioprosthetic tricuspid valve stenosis: A case series. European Heart Journal Case Reports, 3, ytz110. Lilly, S. M., Rome, J., Anwaruddin, S., Shreenivas, S., Desai, N., Silvestry, F. E., Herrmann, H. C., Fassa, A., Himbert, D., Brochet, E., Labbé, J. P., Depoix, J. P., Hvass, U., Vahanian, A., Holoshitz, N., Kenny, D., Hijazi, Z. M. (2013). How should I treat prosthetic tricuspid stenosis in an extreme surgical risk patient? EuroIntervention, 9(3), 407–409. https://doi.org/10.4244/EIJV9I3A64 Tzifa, A., Momenah, T., Al Sahari, A., Al Khalaf, K., Papagiannis, J., & Qureshi, S. A. (2025). Transcatheter valve-in-valve implantation in the tricuspid position. European Journal of Interventional Cardiology, 10(8), A168. https://doi.org/10.4244/EIJV10I8A168 Additional Declarations No competing interests reported. Supplementary Files TTVIV.zip Cite Share Download PDF Status: Under Revision Version 1 posted Editorial decision: Revision requested 28 Mar, 2026 Reviewers agreed at journal 27 Mar, 2026 Reviews received at journal 27 Mar, 2026 Reviewers agreed at journal 25 Mar, 2026 Reviews received at journal 18 May, 2025 Reviewers agreed at journal 15 May, 2025 Reviewers invited by journal 02 Apr, 2025 Editor assigned by journal 27 Mar, 2025 Submission checks completed at journal 27 Mar, 2025 First submitted to journal 26 Mar, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6310439","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":446593681,"identity":"21ef80cd-2e67-45cd-9d78-063693fabdff","order_by":0,"name":"Ayoub Salehi","email":"","orcid":"","institution":"Qom University of Medical Science and Health Services","correspondingAuthor":false,"prefix":"","firstName":"Ayoub","middleName":"","lastName":"Salehi","suffix":""},{"id":446593682,"identity":"b6cd2b93-0d0c-4378-947d-d4967cf85c06","order_by":1,"name":"Ata Firouzi","email":"","orcid":"","institution":"Shahid Rajaee Teacher Training University","correspondingAuthor":false,"prefix":"","firstName":"Ata","middleName":"","lastName":"Firouzi","suffix":""},{"id":446593684,"identity":"5eacf2ed-0506-4793-bc46-0cadb998ee70","order_by":2,"name":"Ezzat Rezai monfared","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABI0lEQVRIiWNgGAWjYBAC+wYgkcBwGMJLqLCp5wczCnBrMTgA1vIcxGZseHAmLUESbIgBAS0MDP/BWhofth1OgIjg03K8/eGHBwy3Gfj5jz9/kNh2OM/4/OrEDw8MGOT5xQ5g90vPgWSJBKAWyYYDiQ0J59KLzW683SwBdJjhzNkJWLXYSSQcAGsxONhwsCGhzJpx242zG0BaEgxuY9diLP+w+QcoxOwPMzY2JLAxM26ecXbzD3xaDGcws0mAtBgAVTcktDknbuDv3YbXFoMzaWwWCQaHeSTOsDHOSDiTZixxg3cbUEQCp18Mjh9/fPNHxWE5/v7jDz7+qLABMs5uBorYyPNLY9cC1cjAg+BIgFVK4FGOAfgPkKJ6FIyCUTAKRgAAAD0MacAV4K7SAAAAAElFTkSuQmCC","orcid":"","institution":"Qom University of Medical Science and Health Services","correspondingAuthor":true,"prefix":"","firstName":"Ezzat","middleName":"Rezai","lastName":"monfared","suffix":""}],"badges":[],"createdAt":"2025-03-26 08:53:07","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6310439/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6310439/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":82076724,"identity":"3662c258-a656-48d6-85a7-855fb6d5900e","added_by":"auto","created_at":"2025-05-06 13:55:36","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":453457,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePositioning of the MyVal prosthesis in relation to the surgical Carpentier-Edwards bioprosthesis. The central marker of the MyVal prosthesis is positioned 3 to 5 mm below the base (ventricular side) of the surgical valve stent frame\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6310439/v1/6504190ee20507b79105e036.png"},{"id":82076725,"identity":"70eecaa2-91a0-4e8f-b961-210b4b16aa5b","added_by":"auto","created_at":"2025-05-06 13:55:36","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":669638,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ea and b. Slow and controlled inflation of the MyVal valve with the balloon in two consecutive stages. This process ensures coaxiality and precise valve positioning without the need for pacing\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6310439/v1/fb8fc557e7d57ef86f4b7649.png"},{"id":82076726,"identity":"ec014ec1-7831-4645-ac69-59dbf5b71cfe","added_by":"auto","created_at":"2025-05-06 13:55:36","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":459346,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFinal valve positioning of the MyVal prosthesis\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-6310439/v1/62014def374c2872ee4b3933.png"},{"id":82079185,"identity":"42e6b850-39e3-4c8c-b45a-c54701fbaada","added_by":"auto","created_at":"2025-05-06 14:11:41","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2815816,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6310439/v1/49f12194-9258-4e9a-ac89-ffbb92cb0803.pdf"},{"id":82076738,"identity":"f5c1c751-be61-46e4-9977-6bf4151decbe","added_by":"auto","created_at":"2025-05-06 13:55:37","extension":"zip","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":12886015,"visible":true,"origin":"","legend":"","description":"","filename":"TTVIV.zip","url":"https://assets-eu.researchsquare.com/files/rs-6310439/v1/632541c3a18b081e2f532972.zip"}],"financialInterests":"No competing interests reported.","formattedTitle":"Defying Limits: Fluoroscopy-Only Transcatheter Tricuspid Valve-in-Valve for Severe Bioprosthetic Stenosis in a Complex Case of Cirrhosis: A Case Report","fulltext":[{"header":"Introduction","content":"\u003cp\u003eSevere tricuspid stenosis (TS) is a rare but significant condition that primarily affects the right side of the heart. It is often associated with rheumatic heart disease and can lead to right heart failure, characterized by ascites, edema, and symptoms of hepatic congestion. When TS becomes advanced, it may present with signs similar to cardiac cirrhosis, making diagnosis and management challenging. The misdiagnosis of TS as hepatic disease may result in inappropriate treatments, such as the use of corticosteroids like prednisolone, which can further exacerbate the condition.[1] [2]\u003c/p\u003e\n\u003cp\u003eFor patients with severe TS, especially those with comorbidities such as cirrhosis and high surgical risk, transcatheter valve-in-valve implantation (TTVIV) offers a promising alternative to traditional surgery. TTVIV is an emerging technique that allows the implantation of a new valve within an existing prosthetic valve. This less invasive procedure is particularly beneficial for patients who are not suitable candidates for open-heart surgery. However, advanced imaging techniques such as CT angiography or intracardiac echocardiography (ICE) are usually required for optimal procedural guidance. In certain cases, such as with clear visualization of the valve stent frame in fluoroscopy, TTVIV can be successfully performed without these advanced imaging modalities.[3]\u003c/p\u003e\n\u003cp\u003eThis case report explores the successful use of TTVIV in a patient with severe TS misdiagnosed as cardiac cirrhosis, highlighting the potential of TTVIV as an effective treatment option even in resource-limited settings.\u003c/p\u003e"},{"header":"Case Presentation","content":"\u003cp\u003e\u003cspan lang=\"\"\u003eA 70-year-old woman with a history of rheumatic heart disease presented to the hospital with severe symptoms of right heart failure. Her medical history includes aortic and mitral valve replacement with Bj\u0026ouml;rk-Shiley mechanical prostheses. 15 years ago, she underwent tricuspid valve repair, and three years later, due to progressive tricuspid regurgitation, she underwent tricuspid valve replacement with a Carpentier-Edwards bioprosthetic valve.\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e\u003cspan lang=\"\"\u003eThis patient was mistakenly diagnosed with Rheumatic\u0026nbsp;\u003c/span\u003e\u003cspan lang=\"\"\u003eCirrhosis and had been treated with prednisolone for several months. However, she developed worsening heart failure symptoms and presented with ascites, lower limb edema, jugular venous distension (JVD), dyspnea, and fatigue. Additionally, the patient exhibited jaundice in both skin and sclera, which correlated with cardiac cirrhosis. Further investigation revealed that the true cause of her symptoms was severe tricuspid stenosis (TS), rather than primary liver disease.And the cause of the patient\u0026apos;s hepatic congestion was due to right-sided heart failure and tricuspid stenosis (TS).\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e\u003cspan lang=\"\"\u003eOn echocardiography, the patient demonstrated severe tricuspid stenosis with a mean gradient (MG) of 8 mmHg, a peak tricuspid pressure half-time (PTH) of 200 ms, and a pulmonary artery pressure (PAP) of 40 mmHg. The inferior vena cava (IVC) was dilated with less than 50% respiratory variation, indicating elevated right atrial pressures. Both the right atrium (RA) and right ventricle (RV) were significantly enlarged, and RV function was moderately impaired. the patient had a preserved ejection fraction (EF) of 50%.\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e\u003cspan lang=\"\"\u003eAdditionally, on angiography, moderate stenosis was observed in the mid part of the left anterior descending (LAD) artery, which was managed with medical follow-up.\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e\u003cspan lang=\"\"\u003eDue to the high surgical risk, which included the patient\u0026apos;s history of cirrhosis, transcatheter tricuspid valve implantation (TTVIV) was selected as the appropriate therapeutic option. The procedure was successfully performed using fluoroscopy as the primary imaging tool, without the need for advanced imaging techniques.\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e\u003cspan lang=\"\"\u003eThe procedure was performed according to the following steps:\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e\u003cspan lang=\"\"\u003eThe MyVal prosthesis, 29mm in size, was selected based on the annular measurements of the tricuspid valve obtained via transesophageal echocardiography (TEE). The decision for this size was made carefully, considering the annulus size and the patient\u0026apos;s anatomy.\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e\u003cspan lang=\"\"\u003eThe True Balloon size was used with caution during the procedure to ensure proper inflation and positioning of the prosthesis. Additionally, no CT angiography was required for this patient, as adequate imaging was available through TEE.\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e\u003cspan lang=\"\"\u003eAccess and Sheath Insertion:\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e\u003cspan lang=\"\"\u003e1.The patient was sedated under conscious sedation, ensuring that they remained stable and comfortable during the procedure.\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e\u003cspan lang=\"\"\u003e2. The right femoral vein was accessed for catheter insertion.\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e\u003cspan lang=\"\"\u003e3. A 14F Python sheath was introduced over a stiff wire into the inferior vena cava (IVC). This sheath provided stable access for further catheter manipulations.\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e\u003cspan lang=\"\"\u003e4. The Agilis NxT steerable introducer was then advanced into the right atrium (RA), providing flexibility and control for the subsequent guidewire advancement.\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e\u003cspan lang=\"\"\u003eGuidewire Passage and Catheter Navigation:\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e\u003cspan lang=\"\"\u003e1. Using the A1 catheter and a hydrophilic wire, the catheter was passed through the bioprosthetic tricuspid valve. This allowed for precise guidance toward the left pulmonary artery (LPA).\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e\u003cspan lang=\"\"\u003e2. A Lunderquist wire was placed in the LPA to provide a stable and secure pathway for the subsequent steps and to facilitate further catheter navigation.\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e\u003cspan lang=\"\"\u003eProsthesis Delivery and Positioning:\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e\u003cspan lang=\"\"\u003e1. The 29mm MyVal prosthesis was mounted onto the delivery catheter in an antegrade fashion, ensuring the proper alignment of the valve prior to insertion.\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e\u003cspan lang=\"\"\u003e2. The delivery system was introduced carefully, ensuring the MyVal logo was facing downward. The catheter was flexed appropriately to direct the valve to the desired location.\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e\u003cspan lang=\"\"\u003e3.The central marker of the MyVal prosthesis was positioned 3 to 5 mm below the base (ventricular side) of the surgical valve stent frame (Carpentier-Edwards bioprosthesis). This was crucial for proper valve function and avoiding any mechanical interference between the prosthesis and the bioprosthetic valve.(Figure 1)\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e\u003cspan lang=\"\"\u003e\u003cspan lang=\"\"\u003e4. Slow and controlled inflation of the MyVal valve was performed. The catheter was carefully adjusted to ensure coaxiality, providing optimal positioning and preventing any malpositioning of the valve. This allowed for accurate valve placement without the need for pacing. (Figure 2a and 2b)\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e\u003cspan lang=\"\"\u003eFinal Valve Positioning:\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e\u003cspan lang=\"\"\u003e1. The MyVal prosthesis was deployed, and its stent frame was visible. The central marker of the valve was positioned below the bioprosthetic valve annulus, ensuring proper valve seating and function. (Figure 3)\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e\u003cspan lang=\"\"\u003e2. Due to the success of the procedure and the proper positioning of the valve, TEE was not required to confirm valve placement.\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e\u003cspan lang=\"\"\u003e3.Post-procedural evaluation was carried out using transthoracic echocardiography (TTE). The valve was functioning properly, and no immediate complications were observed\u003c/span\u003e\u003cspan lang=\"\"\u003e.\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e\u003cspan lang=\"\"\u003eDuring the procedure, the mean gradient of the bioprosthetic tricuspid valve was successfully reduced from 8 mmHg to 3 mmHg. The patient\u0026rsquo;s right atrial pressure was well-managed throughout the procedure, and there were no complications related to the procedure itself. Intraoperative hemodynamics showed improvement, and post-procedure, the patient remained stable.\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e\u003cspan lang=\"\"\u003eAt the 1-month, 6-month, and 1-year follow-ups, the patient remained asymptomatic, with significant resolution of edema and ascites. Echocardiography revealed a well-functioning tricuspid valve prosthesis, and right ventricular function showed improvement. The patient continued to report good quality of life, with no signs of heart failure recurrence.\u003c/span\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eSevere tricuspid valve stenosis (TS) is a rare but significant condition, often associated with rheumatic heart disease. Our patient, a 70-year-old woman, presented with severe TS, right heart failure, and liver cirrhosis. In such cases, treatment is challenging, as traditional surgical interventions carry high risks due to the patient's age and comorbidities. [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e][\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eIn this case, the decision to proceed with transcatheter tricuspid valve-in-valve implantation (TTViV) was based on the patient's persistent symptoms despite medical therapy, including diuretics and steroids for cirrhosis, and her worsening clinical status. TTViV is an emerging approach for managing severe TS, particularly in patients who are not ideal candidates for conventional surgery. The MyVal prosthesis was selected for this patient due to its favorable clinical outcomes and compatibility with the patient's anatomical and functional requirements.[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eSeveral studies have demonstrated that TTViV is a feasible treatment for severe TS, especially in patients with deteriorating bioprosthetic valves. [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] Unlike conventional surgery, TTViV eliminates the need for sternotomy and allows for a faster recovery in patients like ours.[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] Furthermore, this procedure significantly reduced the mean transvalvular gradient from 8 mmHg to 3 mmHg, indicating improved hemodynamics and symptomatic relief.\u003c/p\u003e \u003cp\u003eKey benefits of this intervention included a reduction in right atrial pressure, resolution of edema and ascites, and an overall improvement in the patient's quality of life. Follow-up echocardiography confirmed optimal valve function, with no complications observed, further supporting the safety and efficacy of TTViV in selected patients with severe TS.[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eThe role of imaging in guiding these procedures is crucial. In this case, transesophageal echocardiography (TEE) played a key role in valve selection, annular sizing, and intra-procedural positioning. Although CT angiography was not required for this patient, TEE provided sufficient imaging guidance, eliminating the need for additional modalities. In high-risk patients, TEE serves as an excellent alternative for pre-procedural planning and procedural guidance.[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eAnother important finding was the improvement in right ventricular function following the procedure. Tricuspid stenosis and regurgitation can impair right ventricular performance, which, if left untreated, may lead to progressive heart failure. Successful TS treatment in this patient prevented further cardiac deterioration and significantly enhanced her quality of life.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eTranscatheter tricuspid valve-in-valve implantation (TTViV) is a safe and effective treatment option for patients with severe tricuspid valve stenosis (TS) who are at high surgical risk. This case demonstrates the feasibility of TTViV in restoring tricuspid valve function, reducing right atrial pressure, and significantly improving the patient\u0026rsquo;s symptoms and quality of life.\u003c/p\u003e \u003cp\u003eThe successful implantation of the MyVal prosthesis resulted in a marked reduction in the transvalvular gradient, resolution of edema and ascites, and improved right ventricular function. Follow-up echocardiography confirmed optimal prosthetic valve performance with no complications.\u003c/p\u003e \u003cp\u003eAs the field of structural heart interventions continues to evolve, TTViV offers a promising alternative to surgery for selected high-risk patients. Careful patient selection, precise procedural execution, and close follow-up are essential to achieving favorable outcomes. This case reinforces the growing role of transcatheter therapies in the management of complex valvular heart diseases.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e1. TS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eTricuspid Stenosis\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e2. TTVIV\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eTranscatheter Tricuspid Valve-in-Valve Implantation\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e3. TEE\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eTransesophageal Echocardiography\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e4. PTH\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePressure Half-Time\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e5. PAP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePulmonary Artery Pressure\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e6. IVC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eInferior Vena Cava\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e7. RA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eRight Atrium\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e8. RV\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eRight Ventricle\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e9. LAD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eLeft Anterior Descending\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e10. JVD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eJugular Venous Distension\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e11. CT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eComputed Tomography\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e12. ICE\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eIntracardiac Echocardiography\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003e\u0026nbsp;Written informed consent was obtained from the patient for the publication of this case report and any accompanying images.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e\u0026nbsp;This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eRodriguez Ziccardi, M., Pendela, V. S., \u0026amp; Singhal, M. (2023). Cardiac Cirrhosis. In StatPearls [Internet]. StatPearls Publishing. Last update: April 24, 2023. Available from: https://www.ncbi.nlm.nih.gov/books/NBK431053/\u003c/li\u003e\n \u003cli\u003eGolamari, R., Shams, P., Alahmadi, M. H., \u0026amp; Bhattacharya, P. T. (2024). Tricuspid Stenosis. In StatPearls [Internet]. StatPearls Publishing. Last update: June 22, 2024.\u003c/li\u003e\n \u003cli\u003eChen, S., Dershowitz, L., \u0026amp; George, I. (2021). Transcatheter valve implantation for degenerated tricuspid bioprosthesis and failed tricuspid ring. Texas Heart Institute Journal, 10(5).\u003c/li\u003e\n \u003cli\u003eJeganathan, R., Armstrong, S., Al-Alao, B., \u0026amp; David, T. (2013). The risk and outcomes of reoperative tricuspid valve surgery. Annals of Thoracic Surgery, 95(1), 119-124. https://doi.org/10.1016/j.athoracsur.2012.08.058\u003c/li\u003e\n \u003cli\u003eNakano, K., Eishi, K., Kosakai, Y., Isobe, F., Sasako, Y., Nagata, S., Ueda, H., Kito, Y., \u0026amp; Kawashima, Y. (1996). Ten-year experience with the Carpentier-Edwards pericardial xenograft in the tricuspid position. Journal of Thoracic and Cardiovascular Surgery, 111(4), 605\u0026ndash;612. https://doi.org/10.1016/S0022-5223(96)70312-4\u003c/li\u003e\n \u003cli\u003eHirata, K., Tengan, T., Wake, M., Takahashi, T., Ishimine, T., Yasumoto, H., Nakasu, A., Mototake, H. (2019). Bioprosthetic tricuspid valve stenosis: A case series. European Heart Journal Case Reports, 3, ytz110.\u003c/li\u003e\n \u003cli\u003eLilly, S. M., Rome, J., Anwaruddin, S., Shreenivas, S., Desai, N., Silvestry, F. E., Herrmann, H. C., Fassa, A., Himbert, D., Brochet, E., Labb\u0026eacute;, J. P., Depoix, J. P., Hvass, U., Vahanian, A., Holoshitz, N., Kenny, D., Hijazi, Z. M. (2013). How should I treat prosthetic tricuspid stenosis in an extreme surgical risk patient? EuroIntervention, 9(3), 407\u0026ndash;409. https://doi.org/10.4244/EIJV9I3A64\u003c/li\u003e\n \u003cli\u003eTzifa, A., Momenah, T., Al Sahari, A., Al Khalaf, K., Papagiannis, J., \u0026amp; Qureshi, S. A. (2025). Transcatheter valve-in-valve implantation in the tricuspid position. European Journal of Interventional Cardiology, 10(8), A168. https://doi.org/10.4244/EIJV10I8A168\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"the-egyptian-heart-journal","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"tehj","sideBox":"Learn more about [The Egyptian Heart Journal](https://tehj.springeropen.com)","snPcode":"43044","submissionUrl":"https://submission.springernature.com/new-submission/43044/3","title":"The Egyptian Heart Journal","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Open","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Tricuspid stenosis, transcatheter Valve-in-valve, Fluoroscopy-guided intervention, Tricuspid Bioprosthetic, Case Report","lastPublishedDoi":"10.21203/rs.3.rs-6310439/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6310439/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBackground\u003c/p\u003e\n\u003cp\u003eSevere 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.\u003c/p\u003e\n\u003cp\u003eCase Presentation\u003c/p\u003e\n\u003cp\u003eA 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.\u003c/p\u003e\n\u003cp\u003eEchocardiography 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.\u003c/p\u003e\n\u003cp\u003eConclusions\u003c/p\u003e\n\u003cp\u003eThis 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.\u003c/p\u003e","manuscriptTitle":"Defying Limits: Fluoroscopy-Only Transcatheter Tricuspid Valve-in-Valve for Severe Bioprosthetic Stenosis in a Complex Case of Cirrhosis: A Case Report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-06 13:55:31","doi":"10.21203/rs.3.rs-6310439/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-03-28T22:39:47+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"159612192279411933243916430969026428675","date":"2026-03-28T02:48:34+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-27T10:35:53+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"310611484327178405909963418342093911083","date":"2026-03-25T21:50:01+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-05-19T02:10:11+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"280801311761580473391375156512974337799","date":"2025-05-15T21:34:14+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-04-02T19:19:25+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-03-27T05:44:18+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-03-27T05:43:40+00:00","index":"","fulltext":""},{"type":"submitted","content":"The Egyptian Heart Journal","date":"2025-03-26T08:37:52+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"the-egyptian-heart-journal","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"tehj","sideBox":"Learn more about [The Egyptian Heart Journal](https://tehj.springeropen.com)","snPcode":"43044","submissionUrl":"https://submission.springernature.com/new-submission/43044/3","title":"The Egyptian Heart Journal","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Open","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e2ffed7d-e6ca-4348-929d-fabf745b3076","owner":[],"postedDate":"May 6th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"in-revision","subjectAreas":[],"tags":[],"updatedAt":"2026-03-28T22:53:16+00:00","versionOfRecord":[],"versionCreatedAt":"2025-05-06 13:55:31","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6310439","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6310439","identity":"rs-6310439","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}