Commentary: When things just mix like you hoped

Abstract

In this issue of the Journal, Kalangos and colleagues 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 implantedwith 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. More recently, the Sapien 3 valve was proposed as a valid alternative for mitral and tricuspid valve replacement. 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