A Pascal in ring: Transcatheter edge-to-edge tricuspid repair for severe regurgitation within a surgical annuloplasty ring.

BACKGROUND: Severe tricuspid regurgitation (TR) carries a poor prognosis and its management is particularly challenging in patients with recurrent TR after prior surgical annuloplasty. For those patients redo surgery is often high-risk and transcatheter valve replacement may be anatomically precluded by the presence of a rigid or semi-rigid ring. CASE SUMMARY: We report the case of a 69-year-old woman with a history of rheumatic heart disease, multiple previous cardiac surgeries who presented with heart failure related to severe, symptomatic tricuspid regurgitation caused by leaflet restriction within a previously implanted annuloplasty ring (Carpentier Edwards 30mm). Given a high surgical risk (three prior sternotomies, TRI-SCORE and EuroSCORE II both indicating elevated operative risk) and anatomical screen failure for transcatheter tricuspid valve replacement because of the pre-existing ring, the Heart Team elected transcatheter edge-to-edge repair with the PASCAL system. A single device was implanted in the antero-septal position, achieving no residual leak, without complication. CONCLUSION: Transcatheter edge-to-edge repair with the PASCAL device is technically feasible and effective for the treatment of severe TR recurring within a surgical annuloplasty ring, and should be considered as a valid alternative when redo surgery is high-risk and transcatheter valve replacement is anatomically not feasible.