[HSF] tricuspid noncoaptation

[erdinç naseri]

Opinion requeted for the following case:
67Y/O female . Previously operated by me for severe MR.Mitral semirigid ring annuloplasty 1 year ago.Preop Echo:EF 25%,severe MR ,PAP moderately increased,minimal TR (no measurement of annular diameter),CAG:normal.Intraoperative assessment of mitral valve showed only annular dilatation with normal mitral valvular structure.Nothing is noted about tricuspid valve( trans-septal approach) Readmitted 2 weeks ago with severe ascites and 15 cm palpable liver. TTE showed nil mitral insufficiency , severe TR with absolute noncoaptation of the leaflets.Both Rv and Ra dilated. tricuspid leaflets seem very defficient in tissue with restriction of motion.Tricuspid annular diameter 42 mm.
1.Have I missed something in the 1.st operation?( I mean despite a nearly normal tricuspid valve reported in TTE)
2.Shoul I try annuloplasty and which type or proceed directly with TVR?( 2.nd reop will be awfull)
BTW,  since bioprostheses are about 40% reimbursed by social security institutions here ,how is the idea of implanting a metallic prosthesis in tricuspid position?
erdinc
PS: Prasanna had  a similar case sveral days ago.