Commentary: When things just mix like you hoped

Central MessageIn reoperative patients, difficult surgical operations may be converted to a less complex surgery combined with an interventional procedure.See Article page 121. In reoperative patients, difficult surgical operations may be converted to a less complex surgery combined with an interventional procedure. See Article page 121. In this issue of the Journal, Kalangos and colleagues1Kalangos A. Shatelen N. Sfyridis P. Dalarizou E. Bonou P. Pediatric tricuspid valve replacement with a transcatheter aortic valve (SAPIEN 3).J Thorac Cardiovasc Surg Tech. 2021; 6: 121-124Scopus (2) Google Scholar report a case of pediatric tricuspid valve replacement on a beating heart using the Sapien 3 prosthesis (Edwards Lifesciences, Irvine, Calif). Currently, no tricuspid valve prostheses are available for infants and small children. Therefore, transcatheter valves have been surgically implanted with increasing success in the atrioventricular position with the intention that it allows for subsequent valve expansion in the catheterization laboratory as children grow. Based on its favorable design characteristics and performance in the right ventricular outflow tract position, the Melody valve (Medtronic, Minneapolis, Minn) was initially adapted for left atrioventricular valve replacement with promising results in pediatric patients.2Abdullah I. Ramirez F.B. McElhinney D.B. Lock J.E. del Nido P.J. Emani S. Modification of a stented bovine jugular vein conduit (Melody valve) for surgical mitral valve replacement.Ann Thorac Surg. 2012; 94: e97-e98Abstract Full Text Full Text PDF PubMed Scopus (54) Google Scholar,3Trezzi M. Cetrano E. Iacobelli R. Carotti A. Edwards Sapien 3 valve for mitral replacement in a child after Melody valve endocarditis.Ann Thorac Surg. 2017; 104: e429-e430Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar More recently, the Sapien 3 valve was proposed as a valid alternative for mitral and tricuspid valve replacement.4Pluchinotta F.R. Piekarski B.L. Milani V. Kretschmar O. Burch P.T. Hakami L. et al.Surgical atrioventricular valve replacement with Melody valve in infants and children. A multicenter study.Circ Cardiovasc Interv. 2018; 11: e007145Crossref PubMed Scopus (40) Google Scholar,5Fernandez-Doblas J. Perez-Andreu J. Betrain P. Abella R. Pediatric tricuspid valve replacement with transcatheter bioprosthetic valve: an alternative option in high-risk patients.Semin Thorac Surg. 2020; 32: 1021-1023Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar The stent height is shorter than that of the Melody, and it does not require surgical manipulation beforehand. In small annuli (ie, <19 mm), the Sapien 3 valve certainly appears promising compared with a fixed-diameter prosthesis. However, this valve has thick, stiff leaflets (designed to withstand aortic pressure) that may have poor mobility and may be prone to structural degeneration if complete valve expansion is not achieved. Nevertheless, the choice of the appropriate replacement valve is only one of the steps of a successful challenging surgical operation. Several features of the article merit mention. The authors are to be congratulated for their meticulous planning and execution of a complex operation. Cardiopulmonary bypass was instituted by directly cannulating the abdominal vessels through a retroperitoneal approach. A small right anterior thoracotomy was used for optimal exposure while avoiding resternotomy, and the entire procedure was performed on a beating heart, under transesophageal echocardiographic guidance to avoid any significant compression of the aortic annulus. Ultimately, because the tricuspid annulus was hypoplastic, the newly implanted valve was expanded to the predicted diameter (23 mm), leaving further room for future percutaneous dilatations (nominal valve size of 26 mm). Additional research is warranted to clarify the long-term durability and optimal postprocedural management of tricuspid transcatheter valve replacement. Antiplatelet therapy or even oral anticoagulation might be considered pending further data, along with strict echocardiographic surveillance of the implanted valve. When percutaneous delivery of the appropriate transcatheter valve is not an option, the surgeon's hope is that interventional techniques in combination with open surgery lead to optimal results. Pediatric tricuspid valve replacement with a transcatheter aortic valve (SAPIEN 3)JTCVS TechniquesVol. 6PreviewTricuspid regurgitation (TR) due to dysplasia in children may sometimes lead to gradual right heart failure after remaining asymptomatic during the first years of life. For this reason, tricuspid valve (TV) repair or replacement procedures become mandatory at the stage of symptomatic right heart failure, even when the diameter of the tricuspid orifice remains hypoplastic. We report a novel off-label use of the transcatheter aortic valve SAPIEN 3 (Edwards Lifesciences LLC, Irvine, Calif) in tricuspid position through a small right thoracotomy in a child. Full-Text PDF Open Access