Ann Thorac Surg 2002;73:963-965
© 2002 The Society of Thoracic Surgeons
Case report
Correction of traumatic tricuspid regurgitation using the double orifice technique
Sina L. Moainie, MDa,
T. Sloane Guy, MDa,
Ted Plappert, CVTa,
Joseph H. Gorman, III, MDa,
Robert C. Gorman, MD*a
a Department of Surgery and School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
Accepted for publication July 12, 2001.
* Address reprint requests to Dr Gorman, Department of Surgery, 6 Silverstein, Hospital of the University of Pennsylvania, Philadelphia, PA 19104, USA
e-mail: rcgorman{at}mail.med.upenn.edu
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Abstract
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We present a case of acute traumatic tricuspid regurgitation in a 39-year-old man who was involved in a motor vehicle accident. A large ecchymotic region over the anterior chest wall prompted evaluation by both transthoracic and transesophageal echocardiography which confirmed the valvular injury. At surgery, valvular incompetence was found to be the result of a flail anterior leaflet due to papillary muscle rupture. The valve was successfully repaired using a single stitch double orifice technique in combination with a ring annuloplasty. The valve remains competent 18 months after surgery.
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Introduction
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Tricuspid valve regurgitation is the most commonly reported valvular injury resulting from blunt force trauma [1]. Although rare, this injury is well described and presents with a remarkably reproducible clinical scenario. We present a simple technique for the repair of traumatically induced tricuspid regurgitation due to a flail anterior leaflet.
A 39-year-old man presented to another hospital after being involved in a high-speed motor vehicle accident. The patient was a restrained driver and appeared to be uninjured except for a large ecchymotic region over the anterior chest wall. The patient’s past medical history was significant for having undergone an aortic root replacement 4 years previously. A 31-mm St. Jude composite graft had been placed for a sinus of valsalva aneurysm and associated severe aortic insufficiency.
Because of the evidence of significant anterior chest wall trauma, the patient underwent a transthoracic echocardiogram (TTE), which was concerning for a pericardial effusion. Twenty-four hours after the accident, the patient was transferred to our hospital for further evaluation. A transesophageal echocardiogram (TEE) was performed, which demonstrated a small hemodynamically insignificant loculated pericardial effusion at the apex of the heart. The TEE also demonstrated severe tricuspid regurgitation secondary to a flail anterior leaflet (Figs 1, 2),
which had not been identified on the TTE from the outside hospital. The patient was referred for cardiac surgery.
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Fig 1. Preoperative transesophageal echocardiogram indicating flail anterior leaflet of tricuspid valve (arrow). (LA = left atrium; RA = right atrium; RV = right ventricle.)
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Fig 2. Preoperative transesophageal echocardiogram demonstrating severe tricuspid regurgitation (TR). (LA = left atrium; LV = left ventricle; RV = right ventricle.)
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A redo sternotomy was performed. The inferior vena cava, superior vena cava, and proximal aortic arch were cannulated. Cardiopulmonary bypass was established and the patient was cooled to 32°C. The aorta was clamped and heart arrested with one dose of antegrade cold blood cardioplegia. The tricuspid valve was exposed, and the valve pathology was confirmed to be due to a ruptured anterior papillary muscle. The anterior leaflet of the tricuspid valve prolapsed freely into the right atrium with pressurization of the right ventricle. The valve was repaired by placing one 4-0 Prolene (Ethicon, Somerville, NJ) horizontal mattress suture from the edge of the anterior leaflet to the edge of the septal leaflet. Intraoperative testing of the valve at this point demonstrated a small amount of residual regurgitation. The tricuspid annulus was then sized and found to be 34 mm in diameter.
A 32-mm Carpentier Edwards’s tricuspid annuloplasty ring (Baxter International Inc, Irvine, CA) was selected to mildly reduce the annular size. Placement of the annuloplasty ring improved anterior to septal leaflet coaptation resulting in competence of the valve with intraoperative testing. The atrium was closed and the patient was rewarmed and weaned from cardiopulmonary bypass without difficulty. A postoperative TEE demonstrated no tricuspid stenosis or residual regurgitation (Fig 3).
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Fig 3. Postoperative transesophageal echocardiogram showing successful repair of flail tricuspid valve anterior leaflet with no evidence of tricuspid regurgitation or stenosis. (LA = left atrium; LV = left ventricle; RA = right atrium; RV = right ventricle.)
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A repeat TEE 18 months postoperatively continues to demonstrate normal tricuspid valve function.
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Comment
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Although rare, traumatic tricuspid regurgitation is a well-described result of blunt force trauma that presents with a remarkably reproducible clinical scenario. Patients typically present with a history of a rapid deceleration injury (ie, an automobile accident or fall), diagnosis is typically delayed, the structural lesion is almost invariably a flail anterior leaflet resulting from a ruptured chordae tendenae or papillary muscle, and valve replacement is usually required [2].
Recently, earlier diagnosis has become more commonplace due to the wider application of TEE in evaluation of blunt thoracic trauma. Attempts at repair of traumatically induced tricuspid insufficiency have focused on the use of synthetic material to replace ruptured chordae tendenae or papillary muscles [3]. Chordal transfer techniques to produce and adequately support an anterior leaflet have also been described [4].
Experience with mitral valve repair surgery has demonstrated that while chordal transfer and replacement techniques can be successfully employed, their use can be technically challenging and can be unsuccessful when employed by inexperienced operators [5]. Alfieri and colleagues have reported the use of a so-called double orifice or edge-to-edge technique as a method for correcting significant anterior leaflet prolapse during mitral valve repair surgery [6, 7]. Use of this easily performed technique has been reported in a large series of mitral valve repairs with excellent results and very low incidence of mitral stenosis [6].
In our patient, the Alfieri double barrel technique provided good support for the previously flail anterior leaflet, however, with the Alfieri stitch alone, there was mild-to-moderate regurgitation at the valve commissures. This was relieved by downsizing the tricuspid annulus one size. This reduction of annular size increased the area of leaflet coaptation and promoted full valve competency. We believe this is a technically simple but effective method for repairing tricuspid regurgitation due to a flail anterior or septal leaflet.
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References
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Abstract
Introduction
