Ann Thorac Surg 1996;61:721-722
© 1996 The Society of Thoracic Surgeons
Case Report
Traumatic Tricuspid Valve Injury: Leaflet Resuspension Repair
Joe W. R. Bolton, MD
Department of Cardiothoracic Surgery, Wilford Hall USAF Medical Center, Lackland Air Force Base, Texas
Accepted for publication August 10, 1995.
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Abstract
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Blunt traumatic rupture of the tricuspid valve is exceedingly uncommon, and injury of the tricuspid valve due to penetrating trauma appears to be even more rare. Presented here is a case of tricuspid valve injury due to penetrating cardiac trauma repaired by leaflet resuspension 17 years later. (Ann Thorac Surg 1996;61:721–2)
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Introduction
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The patient is a 37-year-old man who was admitted for evaluation of severe shortness of breath and dyspnea on exertion. His past history was significant for a stab wound to the right ventricle at 20 years of age, which was repaired via an uncomplicated left thoracotomy and oversewing of the stab wound. There was no evaluation of intracardiac structures. Over the next 17 years he required numerous hospital admissions for progressive shortness of breath and was unable to perform even the lightest workload.
On admission, the patient was moderately short of breath and mildly dyspneic. Physical examination was significant for a murmur of tricuspid insufficiency. He had a bounding jugular venous pulse as well as some hepatic enlargement. The electrocardiogram showed atrial fibrillation with a controlled ventricular response of 70 to 80 beats/min. Chest roentgenogram indicated an enlarged right atrium and right ventricle as well as clear lung fields (Fig 1
). An echocardiogram confirmed a massively dilated right atrium and right ventricle and demonstrated unrestricted tricuspid regurgitation with only one tricuspid leaflet identifiable. Cardiac catheterization revealed ventricularization of the right atrial pressures (Fig 2). He was taken to the operating room for tricuspid valve repair or replacement. During cannulation, the tricuspid regurgitant jet was palpated through the right atrial appendage and felt to be totally unrestricted. After institution of cardiopulmonary bypass with bicaval cannulation and aortic cross-clamping the right atrium was opened.
Inspection of the tricuspid valve revealed the septal and posterior leaflets to be intact. The anterior leaflet was almost completely detached from the annulus, being connected only at the commissure of the septal leaflet. The subvalvular mechanism was intact. The annulus was tremendously dilated. The valve was repaired by leaflet resuspension along the annulus with a continuous 4-0 Prolene suture (Ethicon, Somerville, NJ). Because the greatly dilated annulus precluded adequate leaflet approximation, the valve was bicuspidized by closing the cleft between the anterior and posterior leaflets with interrupted figure-of-8 5-0 Prolene suture and a 36-mm Carpentier-Edwards tricuspid valve annuloplasty ring was placed. Testing with saline solution revealed a mild central jet without prolapse. The patient was easily weaned from cardiopulmonary bypass. After decannulation, palpation through the atrial appendage revealed a small tricuspid jet, which was greatly reduced from the torrential flow noted on preoperative palpation. A right atrial pressure measuring line was placed through the tricuspid valve into the right ventricle and on pull-back revealed the expected right atrial pressures, which mimicked the central venous pressure. The ventricularized pressure was absent (Fig 3).
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Fig 3. . Postrepair pressure tracing pull-back. (CVP = central venous pressure; EKG = electrocardiogram; RA = right atrium; RV = right ventricle.)
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He was discharged from the hospital in sinus rhythm on postoperative day 7. Six weeks after the operation he returned to work for the first time since his original injury. At 3-month follow-up, he remained in sinus rhythm and had a decrease in the size of his cardiac shadow by chest roentgenogram (Fig 4).
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Comment
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Isolated traumatic injury to the tricuspid valve and its supporting structures is extremely rare, with only about 100 cases having been reported in the literature [1–3]. Even though 94% of cardiac trauma involves penetrating injuries, the vast majority of reported cases of traumatic tricuspid insufficiency has been due to blunt trauma [3]. Of those injuries involving cardiac valves, aortic valve rupture is most frequent, followed by damage to the mitral valve. Injury to the tricuspid valve is the most rare of valvular injuries [4].
The original treatment of traumatic tricuspid insufficiency was valve repair because the results of valve replacement in this position were poor. Valve replacement with a porcine bioprosthesis did not offer an acceptable longevity and the use of a mechanical valve resulted in an unacceptable incidence of thromboembolism and complications associated with long-term anticoagulation. Unfortunately, an initial poor experience resulting from residual and recurrent valvular insufficiency resulted in long-term nonoperative management because the tricuspid regurgitation could be well tolerated for years [2, 4, 5]. However, because of worsening symptoms nearly all patients eventually came to operation. Valve replacement then became the operation of choice due to the prior poor experience with repair.
Techniques developed with mitral valve repair have improved the ability to attain acceptable results from tricuspid valve repair after blunt or penetrating trauma. Currently, it is recommended that an attempt should be made to repair the valve even if valve replacement at a later date may be inevitable [2–7]. It is important to be aware of a wide variety of techniques because the nature of the injury dictates the method of repair. Most injuries involve the subvalvular structures, and because of the usual delay in diagnosis spanning weeks to years, a dilated annulus is nearly always present. In these cases, it is necessary to address not only the injury to the papillary muscles or chordae, but also the annular dilatation. Occasionally, as in this case, the valve leaflet itself demands attention.
With the techniques available today, once diagnosed, the tricuspid insufficiency should be approached surgically with a plan toward repair. The specific repair is guided by the circumstances and requires ingenuity and innovation. Although valve replacement is sometimes necessary, the reported results after operation, either acute or delayed, have been gratifying. The majority of patients who have undergone reparative operations, as in this case, have been freed from their disability and returned to a productive lifestyle.
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Footnotes
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Address reprint requests to Dr Bolton, Wilford Hall Medical Center/PSST, 2200 Bergquist Dr, Suite 1, Lackland Air Force Base, TX 78236-5300.
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References
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- Linka A, Ritter M, Turina M, et al. Acute tricuspid papillary muscle rupture following blunt chest trauma. Am Heart J 1992;124:799–802.[Medline]
- Kleikamp G, Schnepper U, Kortke H, et al. Tricuspid valve regurgitation following blunt thoracic trauma. Chest 1992;102:1294–6.[Abstract/Free Full Text]
- Dontigny L, Baillot R, Panneton J, et al. Surgical repair of traumatic tricuspid insufficiency: report of three cases. J Trauma 1992;33:266–9.[Medline]
- Liedtke AJ, Demuth WE Jr. Nonpenetrating cardiac injuries: a collective review. Am Heart J 1973;86:678–97.
- Katz NM, Pallas RS. Traumatic rupture of the tricuspid valve: repair by chordal replacements and annuloplasty. J Thorac Cardiovasc Surg 1986;91:310–4.[Abstract]
- Noera G, Sanguinetti M, Pensa P, et al. Tricuspid valve incompetence caused by nonpenetrating thoracic trauma. Ann Thorac Surg 1991;51:320–32.[Abstract/Free Full Text]
- Naja I, Barriuso C, Ninot S, et al. Traumatic rupture of the tricuspid valve. Its conservative surgical treatment. Rev Esp Cardiol 1992;45:64–6.[Medline]
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