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International Society For Minimally Invasive Cardiothoracic Surgery

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Severe Tricuspid Valve Insufficiency- "no Touch Valve Technique"
Kristen Walker, Michael Massoomi, Calvin Choi, Thomas Beaver.
University of Florida, Gainesville, FL, USA.

Severe Tricuspid Valve Insufficiency - "No Touch Valve Technique"
Objective:Elderly frail patients with severe tricuspid regurgitation (TR) are at increased risk for perioperative morbidity and mortality. Chronic pacemaker leads can impinge leaflets in addition to functional etiology from dilation of the tricuspid annulus. We describe a minimally invasive approach to address severe TR employing both leadless pacemaker and inferior cava transcatheter valve technology in two patients.
Methods:Patient A was a 77 yo male with history of ASD repair with Class III NYHA Congestive Heart Failure with EF 20%; and had been turned down for a redo operation for his tricuspid valve. He initially underwent suprahepatic Inferior vena cava transcatheter valve implantation, which was performed as previously described (Innovations 2020; 15(6):577-80). Briefly, two overlapping Z stents (Cook, Bloomington, IN) are placed in the inferior vena cava at the right atrial junction and a S3 transcatheter valve (Edwards, Irvine, CA) is placed within the stents. He had persistent symptoms and subsequently underwent lead extraction with the Cook R/L Excluder system (Cook, Bloomington, IN); and placement of a leadless Micra pacemaker (Medtronic, Minneapolis) with improvement to NYHA I symptoms.Patient B was an 84 yo male with history of prior CABG and EF 20% who presented with class III NYHA heart failure with severe leg edema and abdominal fullness with reversal of hepatic vein flow and impingement of the tricuspid valve leaflets on echocardiography. He underwent extraction of his leads and placement of a leadless Micra pacemaker with improvement, but had persistent edema. One month later, a transcatheter valve was placed in his suprahepatic inferior vena cava and the patient had improved diuretic responsiveness with improvement of his edema and abdominal fullness with NYHA Class I-II symptoms.
Results:Both elderly patients had transcatheter valves and leadless pacing systems with improvement to NYHA Class I/II symptoms. Post-operative echocardiography showed persistent tricuspid valve insufficiency; however, both patients reported dramatic improvement in daily activities with zero morbidity from the procedures.
Conclusions:Elderly higher risk patients with severe tricuspid valve insufficiency secondary to lead impingement can be treated with lead extraction, leadless pacemakers and catheter-based vena cava valves with excellent results.

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