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Ann Thorac Surg 1997;64:1486-1488
© 1997 The Society of Thoracic Surgeons

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Case Report

Partial Mitral Homograft for Tricuspid Valve Repair

Department of Cardiac Surgery, Broussais Hospital, Paris, France

Accepted for publication June 30, 1997.

	Abstract

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We report a case of partial replacement of the tricuspid valve by a mitral homograft in a young drug addict with right heart endocarditis. Operation was indicated because of sudden severe tricuspid regurgitation and persistence of vegetations despite appropriate antibiotic therapy. Partial tricuspid valve replacement was performed with a segment of mitral homograft reinforced by a semirigid prosthetic ring. At 30-month postoperative follow-up the patient was in excellent clinical condition with a satisfactory echocardiographic result.

	Introduction

Top Footnotes Abstract Introduction Comment References

 
Tricuspid valve endocarditis is a common observation in intravenous drug addicts [1]. In the majority of cases the infection responds favorably to selective antibiotic therapy. However, in certain cases it may become resistant to antibacterial agents. Furthermore, major damage to the valve may ensue, and in such circumstances an operation becomes necessary.

Various surgical solutions have been proposed, which depend on the current trends and the surgeon's preference. We report a typical complicated case managed by partial homograft replacement with excellent short-term results.

A 34-year-old man was admitted to a county hospital in early 1995 for fever, chills, severe dyspnea, and lower left thoracic pain. His past medical history was significant for drug abuse and positive human immunodeficiency virus status. Tests revealed septicemia due to Candida albicans and the presence of pulmonary nodules. Heart sounds were normal. Transthoracic echocardiography demonstrated a 13-mm mobile vegetation on the anterior leaflet of the tricuspid valve, minimal tricuspid regurgitation (grade 1/4), and a mean pulmonary artery pressure of 33 mm Hg. Weekly echocardiographic studies showed persistence of the vegetation and progressive aggravation of the tricuspid insufficiency. After a 4-week trial of medical treatment the patient was referred to our department for an operation due to the deterioration of his clinical state.

At admission the patient was febrile and presented right heart failure with jugular distention, hepatic congestion, and lower extremity edema. Chest roentgenography showed multiple foci of nodular infiltration. A new transthoracic echocardiography demonstrated severe tricuspid regurgitation (grade 4/4) in addition to a mobile 15-mm vegetation attached loosely to the anterior leaflet. Mean pulmonary artery pressure was estimated at 35 mm Hg. The patient was scheduled for an urgent operation.

At operation the anterior leaflet was intact (Fig 1) but the chordae were ruptured in such a manner that repair was deemed impossible. A segment of the leaflet corresponding to approximately 50% of its area and harboring vegetations was resected and was replaced by a partial mitral homograft. The homograft was trimmed to remove all excess myocardial tissue except for the tips of the papillary muscles. A large portion of the anterior leaflet including the commissure, the chordae, and the corresponding head of the papillary muscles was selected. The papillary muscle of the mitral homograft was sutured side-to-side to the anterior papillary muscle of the tricuspid valve. The mitral leaflet tissue was then attached to the annulus and to the remnant tricuspid leaflet. A tricuspid Carpentier prosthetic ring was then inserted (Fig 2). Cultures of the resected segments returned positive for Candida albicans. The postoperative period was uneventful, with minimal tricuspid regurgitation at echocardiographic control. The patient was discharged on the seventh postoperative day.

View larger version (100K): [in this window] [in a new window]   Fig 1. . Large vegetation on the anterior leaflet of the tricuspid valve.

View larger version (104K): [in this window] [in a new window]   Fig 2. . Tricuspid valve after partial homograft replacement and prosthetic ring insertion. Arrow points to the graft.

	Comment

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Primary treatment of tricuspid valve endocarditis is medical. Operation addresses those cases for which bacterial resistance, recurrent septic pulmonary emboli with persistent vegetations, or valvular insufficiency with right heart failure are present [1, 2]. In our case reported here the patient presented with all of these characteristics.

The appropriate type of surgical treatment of tricuspid endocarditis for intravenous drug addicts is a matter of extensive debate as opinions diverge concerning the most adequate technique in this category of patients [2, 3]. The fact that intravenous drug addicts easily return to their old habits and expose themselves to reinfection is the basic complicating factor.

Arbulu and associates [4] have for decades advocated an excision-only treatment modality. There are certain undeniable advantages that justify this attitude. Excision eradicates the site of infection, and if the responsible agent is particularly resistant to therapy, this is probably the only manner of dealing with it. However, excision-only treatment exposes the patient to potential or overt right heart failure, especially in the presence of high pulmonary pressures. Physical efforts become difficult and the patient is rendered handicapped for the remainder of his life. Furthermore, the liver may suffer and centrolobular fibrosis can develop [2]. In our opinion, the excision-only attitude belongs to a period in which no other alternative but prosthetic replacement was available.

Replacement of the tricuspid valve by a prosthesis (biological or mechanical) during the acute phase of infection is questionable. Recurrence is likely because of constant exposure to reinfection. In addition, porcine valve replacement commits the patient to a second operation as rapid degeneration of the bioprosthesis is a common event in a young patient. Whenever replacement by a bioprosthesis is decided on, a two-stage operation would be a wiser attitude, whereby the valve is first excised and later replaced provided the patient's hemodynamic status is acceptable [2].

Valve repair is an excellent surgical technique when possible and yields satisfactory results. The advantages include improved hemodynamics and a low rate of recurrence. However, in the presence of extensive lesions valve repair should not be undertaken [5].

Homograft replacement of the tricuspid valve is an appealing alternative. In 1993 Pomar and Mestres [6] published their 16-month-old results of total tricuspid replacement by a mitral homograft and demonstrated the feasibility and the reliability of the operation. A few years ago we reported a series of total and partial replacement of the mitral valve with mitral homografts [7]. A later report by Acar and colleagues [8] presented the case of a patient suffering from endocarditis involving both the mitral and the tricuspid valves who underwent double valvular replacement with two separate homografts.

Partial tricuspid replacement is preferable to total replacement. Anatomically, the subvalvular apparatus of the tricuspid valve is not as well-defined and organized as is the mitral valve. For instance, the chordae to the anteroseptal commissure originate directly from the right ventricular wall without papillary muscle support. Total replacement is therefore difficult and requires technical skills. On the other hand, the anterior leaflet is functionally the most important portion of the valve. In cases of severe deterioration, partial or total replacement of the leaflet allows the restoration of a normally functioning valve. The technical details are similar to those of implantation in the mitral position and have been described elsewhere [7]. In the absence of recipient papillary muscle the remnant papillary muscle of the homograft can be inserted into the ventricular wall through a transmyocardial incision. The use of a semirigid prosthetic ring for suture reinforcement is a logical addition. To our knowledge, the recurrence of infection at the site of a prosthetic ring is extremely rare.

In conclusion, partial replacement of the tricuspid valve by a mitral homograft extends the possibilities of repair in tricuspid endocarditis.

	Footnotes

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Address reprint requests to Dr Acar, Department of Cardiac Surgery, Bichat Hospital, Rue Henri Huchard, 75018 Paris, France.

	References

Top Footnotes Abstract Introduction Comment References

 

1. Chan P, Ogilgy D, Segal B. Tricuspid valve endocarditis. Am Heart J 1989;117:1140–6.[Medline]
2. Stern HJ, Sisto DA, Strom JA, et al. Immediate tricuspid valve replacement for endocarditis: indications and results. J Thorac Cardiovasc Surg 1986;91:163–7.[Abstract]
3. Yee ES, Khonsari S. Right-sided infective endocarditis: valvuloplasry, valvectomy or replacement. J Cardiovasc Surg 1989;30:744–8.[Medline]
4. Arbulu A, Holmes RJ, Asfaw I. Surgical treatment of intractable right-sided infective endocarditis in drug addicts: 25 years' experience. J Heart Valve Dis 1993;2:129–37.[Medline]
5. Yee ES, Ullyot D. Reparative approach for right-sided endocarditis: operative considerations and results of valvuloplasty. J Thorac Cardiovasc Surg 1988;96:133–40.[Abstract]
6. Pomar JL, Mestres CA. Tricuspid valve replacement using a mitral homograft: surgical technique and initial results. J Heart Valve Dis 1993;2:125–8.[Medline]
7. Acar C, Tolan M, Berrebi A, et al. Homograft replacement of the mitral valve. J Thorac Cardiovasc Surg 1996;111:367–80.[Abstract/Free Full Text]
8. Acar C, Iung B, Cormier B, et al. Double mitral homograft for recurrent bacterial endocarditis of the mitral and the tricuspid valves. J Heart Valve Dis 1994;3:470–2.[Medline]

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Christophe Acar Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Ramsheyi, A. Articles by Acar, C. Search for Related Content PubMed PubMed Citation Articles by Ramsheyi, A. Articles by Acar, C.