PERCUTANEOUS THERAPY OF SEVERE TRICUSPID REGURGITATION USING CAVAL VALVE IMPLANTION (CAVI)
Mawri S, Wang DD, and Frisoli T. PERCUTANEOUS THERAPY OF SEVERE TRICUSPID REGURGITATION USING CAVAL VALVE IMPLANTION (CAVI). J Am Coll Cardiol 2019; 73(9):3000.
J Am Coll Cardiol
Background: Severe tricuspid regurgitation (TR) is associated with increased morbidity and mortality. Many patients have high or inoperable surgical risk. Caval valve implant (CAVI) is a potential percutaneous therapy and efficacious alternative to surgery. Case: An symptomatic 83-year-old man with severe TR refractory to maximal medical therapy with diuretics was referred to be evaluated for percutaneous interventions for his valvular disease. His medical history included PAD and CAD s/p 3-vessel CABG. RHC demonstrated RA pressure of 16 mmHg, PAP of 40 / 16 mmHg (mean 27 mmHg), PCWP of 23 mmHg and elevated V-wave of 31 mmHg. He was declined for surgical intervention due to prohibitive surgical risk. Pre-procedural planning using CT with 3-D reconstruction allowed for determination of RA-IVC landing zone diameter. The procedure was performed through right IJ and right femoral vein (RFV). IVUS was performed to confirm sizing at the RA/IVC junction. A Nitrix wire was advanced into SVC, snared from the RIJ and externalized. Cook Z Stents were used as landing zone to anchor the valve. A reliant balloon helped prevent stent migration. Multiple Z stents were deployed into RA/IVC junction under IVUS guidance, with final IVC/RA junction dimensions reduced to 27.4 × 29.4 mm. A 29mm S3 valve was placed at cavo-atrial junction within the Z-stents. Decision-making: Our CAVI case highlights key points. First, we used 4 Z-stents suggesting the necessity to use as many vascular stents as needed to ensure adequate downsizing of the IVC/RA junction diameter to provide successful mounting of the valve. Secondly, it emphasizes the important utility of IVUS to achieve IVC diameter confirmation before valve deployment. Thirdly, it demonstrates an efficient means to creating a rail for stent and valve delivery via externalization of the guidewire from RFV out through the RIJ. Fourth, it illustrates the use of a Reliant balloon as a successful strategy to preventing stent migration, which had occurred with the first placed Z-stent. Conclusion: There is increasing recognition of the poor outcomes associated with severe TR. Caval valve implant (CAVI) is a novel percutaneous intervention for management of severe TR.
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