Severe postransplant tricuspid regurgitation: treatment with the PASCAL system

We report the case of a 43-year-old man with a past medical history of heart transplantation in 2017 due to ischemic dilated cardiomyopathy. One month after the transplant, after routine endomyocardial biopsy, a follow-up transthoracic echocardiogram revealed the presence of moderate tricuspid regurgitation (TR). As a result, clinical and echocardiographic monitoring was initiated. Four years later, the patient’s functional class progressed to NYHA FC III-IV with signs of congestion. Transthoracic echocardiography showed good biventricular function, dilated right chambers, and severe TR with a vena contracta width of 12 mm, and an effective regurgitant orifice of 0.45 cm² due a prolapsed septal leaflet (figure 1A,B and videos 1-2 of the supplementary data). A transesophageal echocardiogram confirmed that the severe TR was due to a prolapsed septal leaflet in the portion proximal to the posteroseptal commissure, with signs of ruptured chordae tendineae (figure 1C,E; videos 3-5 of the supplementary data). The case was discussed with the heart team, which decided to perform a percutaneous edge-to-edge repair due to the high surgical risk. Due to its availability in our center, a PASCAL Ace device (Edwards Lifesciences, United States) was successfully implanted between the septal and posterior leaflets at the site of the prolapse (figure...