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Ann Thorac Surg 1999;68:1858-1860
© 1999 The Society of Thoracic Surgeons

Case Reports

Stentless tricuspid valve replacement

Thomas Walther, MDa, Volkmar Falk, MDa, Johannes Schneider, MDa, Claudia Walther, MDa, Friedrich W. Mohr, MD, PhDa

a Department of Cardiac Surgery, Heart Center, University of Leipzig, Leipzig, Germany

Address reprint requests to Dr Walther, Universität Leipzig, Herzzentrum, Klinik für Herzchirurgie, Russenstr 19, 04289 Leipzig, Germany
e-mail: walt{at}medizin.uni-leipzig.de


   Abstract
Top
 Abstract
Introduction
 Comment
 References
 
Stentless tricuspid valve replacement was performed in a 21-year-old patient with severe destructive tricuspid valve endocarditis resistant to medical therapy. Postoperative recovery was uneventful. Stentless atrioventricular valves are considered an additional treatment option besides stented valves or homograft implantations for severe right-sided endocarditis. Transvalvular hemodynamics are excellent, and right ventricular function can be preserved by suspending the valve at the papillary muscles.


   Introduction
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 Abstract
 Introduction
Comment
 References
 
Tricuspid valve endocarditis is initially treated with intravenous antibiotics. If sepsis persists or if severe tricuspid regurgitation develops, surgical therapy can be required. If the tricuspid valve is partially infected, reconstruction can be possible, but in the presence of complete destruction, tricuspid valve replacement has to be performed. Conventional biological or mechanical valves as well as complete or partial mitral homografts have been used under such circumstances [1–3]. Overall short- and long-term results for tricuspid valve replacement are not encouraging [1, 4]. We report a case of severe destructive tricuspid valve endocarditis treated with stentless valve replacement.

A 21-year-old woman with preexisting ventricular septal defect contracted a systemic infection (Streptococcus viridans) during dental work. She had no history of intravenous drug abuse. Despite specific antibiotic therapy over 3 weeks, the patient had persistent signs of sepsis and development of severe tricuspid valve endocarditis. On subsequent admission for a cardiac surgical procedure, the patient had severe right heart failure. Echocardiography revealed complete destruction of the tricuspid valve, massive vegetations, severe regurgitation, and a ventricular septal defect 8 mm in diameter located directly under the aortic valve. Urgent tricuspid valve operation was indicated, and informed consent was signed.

Intraoperatively the remnants of the infected tricuspid valve were completely excised followed by careful debridement. Both papillary muscles were free from infection. The ventricular septal defect was closed using a pericardial patch.

For tricuspid valve replacement, a 30-mm stentless pericardial atrioventricular valve (quadrileaflet mitral valve; Glycar Inc, Irene, South Africa) was chosen (Fig 1). This valve is made from four pieces of bovine pericardium and is completely flexible. Until insertion, it is mounted on a plastic holder. The quadrileaflet mitral valve has standard glutaraldehyde fixation and polyol tanning to prevent calcification. Its use was approved by our local Ethics Committee and by the Freiburg International Ethics Committee, and it is currently being evaluated in a clinical trial.



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  		Fig 1. Quadrileaflet mitral valve: (Top) inflow aspect showing the four leaflets and the flexible annulus consisting of three layers of pericardium and (Bottom) lateral view with papillary flaps.

 
The papillary flaps of the stentless valve were attached to the right ventricular papillary muscles using two Teflon-armed 3-0 Tevdek stitches each. Then the annulus was continuously sutured to the tricuspid valve annulus with 3-0 Prolene. The aortic clamp was released after 43 minutes. Intraoperative transesophageal echocardiography showed a competent tricuspid valve.

The patient recovered well and was in sinus rhythm, had good right heart function, and had a perfectly working prosthesis postoperatively. Transvalvular blood flow was nonturbulent at 1.3 m/s with no major pressure gradient. The patient was placed on a 6-week course of antibiotics, and she was discharged after 7 days in good health without anticoagulant treatment.


   Comment
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 Abstract
 Introduction
 Comment
References
 
Tricuspid valve replacement for severe endocarditis is a challenge for cardiac surgeons, and as yet, no standard therapy exists [1, 4]. Better valve substitutes are required. Mitral valve homografts have been used in select patients [2, 3], but these homografts are associated with problems such as graft availability, exact sizing, implantation technique, and dehiscence of the papillary muscle anastomosis [5]. The stentless bioprosthesis resembles the native heart valve in function. During the past 10 years, stentless aortic valve replacement has become standard therapy. Stentless mitral valves have been evaluated in the experimental setting [6]. Now the first clinical trials are underway and reveal promising 1-year results. The use of stentless valves in severe right-sided endocarditis is justified and technically feasible.

There are several advantages to stentless atrioventricular valves. They are always available on the shelf, sizing can be exact, and there are no variations in valve size. The relatively large coaptation area results in a low incidence of valvular incompetence. As such, the quadrileaflet mitral valve is very forgiving. Tissue strength is excellent, and an additional anticalcification treatment can be applied. This should guarantee longevity. Implantation of a stentless atrioventricular valve can be performed in a standard fashion. Fixation of the papillary flaps to the papillary muscles is advantageous to preserve the subvalvular muscular apparatus and the continuity between the annulus and the ventricle [4]. Thus right ventricular function might improve further postoperatively. Other advantages of the stentless bioprosthesis are its design from biological tissue only for patients with endocarditis and the absence of a requirement of anticoagulation therapy postoperatively. Long-term results are needed but in the meantime, the use of a stentless prosthesis with suspension at the papillary muscles might be a good alternative for tricuspid valve replacement.


   Acknowledgments
 
We thank Anke Heinz for the artwork.


   References
Top
 Abstract
 Introduction
 Comment
 References
 

  1. Munro A.I., Jamieson W.R.E., Tyers G.F.O., Germann E. Tricuspid valve replacement. Ann Thorac Surg 1995;60:S470-S474.
  2. Katsumata T., Westaby S. Mitral homograft replacement of the tricuspid valve for endocarditis. Ann Thorac Surg 1997;63:1480-1482.[Abstract/Free Full Text]
  3. Prat A., Fabre O.H., Vincentelli A., Doisy V., Shaaban G. Ross operation and mitral homograft for aortic and tricuspid valve endocarditis. Ann Thorac Surg 1998;65:1450-1452.[Abstract/Free Full Text]
  4. Duran C.M. Tricuspid valve replacement. J Heart Valve Dis 1996;5:168.[Medline]
  5. Reardon M.J., Oury J.H. Evolving experience with cryopreserved mitral valve allografts. Curr Opin Cardiol 1998;13:85-90.[Medline]
  6. Frater R.W.M., Liao K., Seifter E. Stentless chordally supported mitral bioprosthetic valve. In: Grabbay S., Frater R.W.G., eds. New horizons and the future of heart valve bioprostheses. Austin, TX: Silent Partners Inc, 1994:103-119.
Accepted for publication April 28, 1999.


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