Heart failure (HF) and chronic kidney disease (CKD) both carry significant risk for sudden cardiac death, hospitalization, and mortality; when combined, however, they markedly increase the risk of morbidity and mortality. Device therapies such as implantable cardioverter-defibrillators (ICDs) and cardiac resynchronization therapy (CRT) are treatments proven to have significant benefit on clinical outcomes in select patients with HF. However, the majority of studies supporting the use of these devices have limited data on patients with CKD or end-stage renal disease. In this review, we discuss the intersection of HF and CKD as it relates to progressive HF and the risk of sudden death. Although these disorders are common and have a poor prognosis, the evidence available for guiding treatment decisions for the use of ICD and CRT devices in these patients is lacking. Given this lack of clear evidence, pragmatic clinical trials and comparative effectiveness studies are needed to help identify the appropriate use of ICD and CRT devices in this high-risk population of patients with HF and CKD.
T ranscatheter valve-in-valve implantation has gained substantial momentum as a viable alternative to surgical valve replacement in patients who are thought to be at high risk for adverse perioperative outcomes. Valve-in-valve implantation of the Edwards Sapien ® valve (Edwards Lifesciences Corporation; Irvine, Calif ) in the tricuspid position is a relatively new procedure, and few cases have been reported. We describe the percutaneous delivery of the Edwards Sapien valve across an existing bioprosthetic tricuspid valve in a patient with metastatic testicular cancer who had undergone multiple previous thoracic operations. We discuss the technical aspects of the case and briefly review the usefulness of transcatheter valve-in-valve techniques in the tricuspid position. Case ReportIn June 2013, a 38-year-old man with severe tricuspid stenosis and regurgitation presented with New York Heart Association functional class III right-sided heart failure. His medical history included malignant neoplasm of the testes, for which he had undergone radical left orchiectomy in 1995 at the age of 19 years. That same year, he underwent exploratory laparotomy, left nephrectomy, bilateral pulmonary resections through a median sternotomy, and removal of multiple metastatic lesions. In 1996, he underwent right thoracotomy to remove additional metastases. During this operation, his tricuspid valve was replaced with a 27-mm Carpentier-Edwards ® Perimount ® bioprosthesis (Edwards Lifesciences) because of valvular involvement of the malignancy. He did well until 2009, when he presented with atrial flutter and underwent successful radiofrequency ablation. He emergently presented in 2012 with atrial flutter that was medically managed with success; the treatment included therapeutic oral anticoagulation.The patient had remained free of cancer for more than 15 years. However, in the 2 years before his current presentation, he had become more fatigued, with worsening shortness of breath and peripheral edema. Physical examination and transthoracic echocardiograms revealed severe tricuspid bioprosthesis stenosis with central regurgitation. The mean transvalvular gradient was 13 mmHg and the peak gradient was 22 mmHg (Fig. 1A), with a peak velocity of 2.34 m/s. No evidence of thrombus, vegetation, or abscess was seen. The right atrial cavity was severely dilated, and the Case Reports
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