Page 32 - Journal of Structural Heart Disease Volume 3, Issue 2

Case Report
58
placement and multi-organ transplantation but was felt to not be a candidate for either. Percutaneous TV replacement was considered as a potential palliation.
The patient underwent transcatheter TV implanta- tion using a 29-mm Edwards Sapien XT valve without pre-stenting of the ring. The procedure was guided by TEE and uoroscopy and performed under gen- eral anesthesia (Figure 3A). Via a femoral venous approach, a 30-mm × 4-cm PTS-X balloon (Numed) was in ated across the annuloplasty ring to reveal a 27–28 mm waist (Figure 4A) with evidence of mild to moderate residual regurgitation within the medial “open” portion of the ring (Figure 3B). Right coronary angiography showed no evidence of compression. A 29-mm Edwards Sapien XT valve and delivery system were introduced into the tricuspid position. The valve
was deployed with rapid pacing at 160 bpm using the existing permanent pacemaker (Figure 4B). Following valve deployment, TEE imaging demonstrated mod- erate medial PVL and mild lateral PVL (Figure 3C). The medial PVL was successfully crossed with a guide wire and catheter, and two Amplatzer vascular plugs (AVP II, St. Jude Medical) were successfully placed, reduc- ing the PVL to mild (Figure 3D).
The patient tolerated the procedure well and was weaned from all pressor support within 1 week, re- maining hemodynamically stable thereafter. Her renal function improved dramatically, and she was able to discontinue dialysis 1 month post-intervention. Fol- low-up transthoracic echocardiograms showed mild TR with no stenosis 8 months post-intervention. Her functional capacity improved from New York Heart
AB
CD
Figure 3. Transesophageal Doppler echocardiographic images. Panel A. Tricuspid valve color Doppler pre-deployment demonstrating severe regurgitation. Panel B. Balloon in ation across the native valve demonstrated residual medial regurgitation in the open part of the annuloplasty ring. Panel C. Post-deployment of a 29-mm Sapien XT valve showed moderate medial and mild lateral paravalvular leak (PVL). Panel D. Post-deployment of Amplatzer vascular plugs medially resulted in a reduction of PVL. No central regurgitation was noted. RA = right atrium; LA = left atrium; TV = tricuspid valve; AV = aortic valve.
Journal of Structural Heart Disease, April 2017 Volume 3, Issue 2:55-61