Transfemoral tricuspid valve-in-ring implantation using the edwards Sapien XT valve: one-year follow-up.

after multidisciplinary evaluation, 3 high-risk patients underwent transfemoral tricuspid valve-in-ring implantation (TVIRI) for refractory congestive heart failure because of deterioration of their tricuspid surgery, using Sapien XT valves (Edwards Lifesciences Inc, Irvine, CA). Patient 1: 44-year-old man, drug abuse, 4 episodes of tricus-pid endocarditis, 2 previous cardiac surgeries for mitral homo-graft in tricuspid position with 30-mm Classic Carpentier Edwards annuloplasty ring (2001), presenting with massive central tricuspid regurgitation (TR; Figure 1A). Patient 2: 69-year-old man, tricuspid endocarditis treated by valve replacement with 30-mm bioprosthesis (1982), mitral homograft in tricuspid position with 30-mm Carpentier Edwards annuloplasty ring and coronary artery bypass grafting (1998), presenting severe homograft degeneration with stenosis and severe central TR (Figure 1B). Patients 3: 58-year-old woman, rheumatic heart disease, mitral valve repair, and tricuspid annuloplasty with a 32-mm rigid Carpentier Edwards annuloplasty ring (1988), mechanical mitral valve replacement (1999), with severe central TR (Figure 1C). The choice of the Sapien XT valve size was based on ring diameters determined by computed tomography, three-dimensional (3D) transesophageal echocardiography and flu-oroscopy, with the aim of implanting a valve whose diameter was closest to the mean inner diameter of the ring (Figure 2). However, considering that 23-mm Sapien XT valves would lead to high transprothetic gradients, only 26-and 29-mm valves were considered. All procedures were performed via the transvenous femoral approach, under general anesthesia and transesophageal echo-cardiography guidance. The tricuspid valve was crossed with a Judkins right or a balloon floating catheter placed through a Mullins sheath. A J-preshaped 0.035 Amplatz SuperStiff wire was placed at the apex of the right ventricle. Then, the Sapien XT valve, mounted on a Novaflex catheter in an antegrade position, was deployed by slow balloon inflation under rapid ventricular pacing. Rapid ventricular pacing was performed using a permanent pacemaker via the epicardium (patient 1) or the coronary sinus (patients 2 and 3). In all patients, a 26-mm Sapien XT valve was successfully implanted. After the final results had been evaluated in the catheterization laboratory by echocardiography and fluoroscopy, patients underwent a computed tomographic scan before discharge using computed 3D reconstruction (Figure 3). On predischarge echocardiographic examination, mean transvalvular gradients ranged from 3 to 5 mm Hg and para-valvular TR around the Sapien valve was mild in patient 1, absent in patient 2, and moderate-to-severe in patient 3 (Figure 1A′–C′; Movies I–IV in the Data Supplement). At 30-day follow-up, there was no complication and all patients had …