Ann Thorac Surg 2002;73:1808-1812
© 2002 The Society of Thoracic Surgeons
Original article: cardiovascular
Partial replacement of the tricuspid valve by mitral homografts in acute endocarditis
Jean-Paul A. Couetil, MD*a,
Pantelis G. Argyriadis, MDa,
Abdel Shafy, MDa,
Ariel Cohen, MDa,
Alain J. Berrebi, MDa,
Didier F. Loulmet, MDa,
Juan-Carlos Chachques, MD, PhDa,
Alain F. Carpentier, MD, PhDa
a Department of Cardiovascular Surgery, Bichat and Georges Pompidou Hospitals, Paris, France
Accepted for publication February 27, 2002.
* Address reprint requests to Dr Couetil, Bichat Hospital, 46, rue Henri Huchard, 75018 Paris, France
e-mail: jean-paul.couetil{at}bch.ap-hop-paris.fr
 |
Abstract
|
|---|
Background. Seven patients with acute tricuspid endocarditis underwent partial replacement of the tricuspid valve using mitral homograft tissue. Valve function was evaluated at midterm.
Methods. Operative indications were uncontrolled sepsis in all cases associated with heart failure symptoms in 3 patients and septic pulmonary emboli in 2 patients. These patients were referred to our institution after a course of antibiotic treatment ranging from 7 to 12 weeks. Lesions found at the level of the anterior leaflet of the tricuspid valve were vegetations and rupture of more than half of the marginal cords in all patients. Vegetations were also found on the posterior leaflet in 5 patients. In all instances the septal leaflet was free of lesions. The aortic valve was involved in 4 patients and the pulmonary valve in 1 patient. All patients underwent resection of the anterior and posterior leaflets of the tricuspid valve with their corresponding papillary muscles leaving the septal leaflet in place. Replacement of the tricuspid valve was performed through a right longitudinal atrial access, using the anterior leaflet of a mitral homograft alone in 3 patients and the anterior leaflet with part of posterior leaflet in 4 patients. Associated procedures included aortic valve replacement by a homograft (n = 4) and pulmonary valve reconstruction (n = 1).
Results. No hospital deaths are reported. One late death, at 16 months, is reported after reoperation due to recurrent aortic valve endocarditis. At midterm (mean follow-up, 30 months) patients had excellent functional status and normal valvular function during echocardiographic studies.
Conclusions. We conclude that when the degree of tricuspid valve destruction prevents repair, partial homograft replacement can be used as an extension of the already existing reconstructive techniques, with excellent functional results.
|
Introduction
|
|---|
The incidence of right-sided endocarditis is increasing in parallel with more widespread intravenous drug abuse, increasing prevalence of immunodeficiency diseases, and the use of intravenous access for monitoring and diagnostic procedures. The tricuspid valve is involved in the majority of patients, pulmonary valve endocarditis remaining rare. In most patients, tricuspid endocarditis resolves with medical treatment [1]. During the past 30 years, several surgical techniques have been proposed for tricuspid endocarditis unresponsive to medical therapy [2, 3]. Among these, tricuspidectomy was used to completely eliminate infected tissues; however, right ventricular dysfunction was observed at long-term follow-up. Progress in valve repair techniques emerged as the gold standard in surgical treatment in mitral and tricuspid endocarditis [4–8]. At Broussais Hospital the surgical strategy applied for infections of the atrioventricular valves is based on three principles: early indication for operation, extensive debridement of all infected tissue, and repair of the valve apparatus [9]. Nevertheless, in rare circumstances, especially when patients are referred late for operation, the extent of the lesions goes beyond the possibility of repair techniques. In these patients, encouraged by early reports on the use of partial mitral homograft in mitral endocarditis, we used partial mitral homografts for partial tricuspid replacement [10]. The purpose of this article is to describe an original technique for partial tricuspid replacement in acute endocarditis using mitral homograft material and to report the midterm results.
|
Material and methods
|
|---|
Seven patients (five men and two women) aged from 24 to 47 years (mean, 34 years) underwent partial tricuspid valve replacement by a mitral homograft for acute endocarditis. Clinical characteristics of the patients are reported in Table 1.
Operation was indicated because of persistent sepsis despite a long-term antibiotic treatment (7 to 12 weeks) in all patients, signs of heart failure in 3, and septic pulmonary embolization in 2 patients. Preoperative transesophageal echocardiography demonstrated large vegetations on the tricuspid valve associated with moderate to severe (3+ to 4+) tricuspid regurgitation in all patients. In 4 patients, the infectious process also affected the aortic valve and in 1 patient the pulmonary valve. Echocardiographic measurement of the tricuspid orifice size (anteroposterior and transverse diameters) permitted an equivalent size of cryopreserved mitral homograft to be selected from the tissue bank. The distance between the tricuspid annulus and the head of the tricuspid papillary muscles was not taken into consideration for the choice of the homograft. Operation was performed through a median sternotomy on cardiopulmonary bypass with cardioplegic arrest using cold blood cardioplegia and moderate systemic hypothermia. Both vena cava were cannulated and snared. The tricuspid orifice was exposed through a horizontal right atriotomy parallel to the atrioventricular groove.
Operative findings
In all patients, large vegetations were found on the anterior leaflet of the tricuspid valve and in 5 patients on the posterior leaflet. The part of the anterior leaflet that was free of vegetations was inflammatory and friable and only less than half of the marginal cords of the anterior leaflet of the tricuspid valve were smooth and free of disease. In 4 patients, vegetations associated with destruction of the aortic valve were observed with abscess of the aortic annulus in 2. In 1 patient, the pulmonary valve was affected by the infectious process (Table 1).
Debridement of the tricuspid valve
The first step consisted of excision of all infected tissue. The excision affected the anterior and the posterior leaflet of the tricuspid valve in all patients including the anterior and the median papillary muscle. Because of the wide valve defect, tricuspid valve repair was impossible and partial replacement with a mitral homograft was preferred to prostheses.
Preparation of the mitral homograft
In 3 patients, only the anterior leaflet of the mitral homograft was used (Fig 1).
The mitral homograft was divided into its two constituent leaflets by dividing the commissural areas of cusp tissue and the papillary muscles between the attachments of anterior and posterior leaflet chordae.
View larger version (28K):
[in this window]
[in a new window]
|
Fig 1. The mitral homograft was divided into its two constituent leaflets by dividing the commissural areas of cusp tissue and the papillary muscles between the attachments of anterior and posterior leaflet chordae. Only the anterior leaflet of the mitral homograft was used.
|
|
In 4 patients, because of an enlarged tricuspid surface area, the anterior leaflet and the posterior commissure with the adjacent part of the posterior leaflet (P3) of the mitral homograft were used (Fig 2).
All excess tissue was excised from the annular edge of the anterior leaflet and the papillary muscles were trimmed so as to leave the minimal muscular tissue below the fibrous capsular attachment of the chordae.
View larger version (32K):
[in this window]
[in a new window]
|
Fig 2. The anterior leaflet and the posterior commissure with the adjacent part of the posterior leaflet (P3) of the mitral homograft.
|
|
Insertion of the mitral homograft in the tricuspid position
The technique used was identical for all 7 patients. We began by suturing the homograft to the tricuspid annulus from left to right, starting at the anteroseptal commissure of the tricuspid valve up to the middle of the anterior mitral leaflet (Fig 3).
Then, we inserted the anterior papillary muscle of the homograft in the right ventricle. To determine the correct position of the anterior papillary muscle in the right ventricle, the free margin of the homograft corresponding to the sutured part was pulled against the septal part of the tricuspid annulus in systolic position and temporarily fixed with a stay suture. The anterior papillary muscle was positioned against the free wall of the right ventricle with its cords in tension and in proper orientation. Once the correct position was determined, some trabeculations of the right ventricle were trimmed creating a solid base of implantation. The anterior papillary muscle of the homograft was then sutured with 4-0 Prolene (Ethicon, Somerville, NJ). The remaining suture of the mitral homogaft to the tricuspid annulus was completed up to P3, followed by the implantation of the posterior papillary muscle of the homograft in the right ventricle using the same technique as for positioning the anterior papillary muscle. P3 was sutured side-to-side to the septal leaflet to expand the surface of this leaflet (Fig 4).
A Carpentier rigid tricuspid annuloplasty ring was then selected according to the usual criteria and sutured into position. The repair was tested intraoperatively with saline under pressure and transesophageal echocardiography.
View larger version (14K):
[in this window]
[in a new window]
|
Fig 3. The insertion of the homograft starts by suturing the homograft to the tricuspid annulus from left to right (arrow), at the anteroseptal commissure of the tricuspid valve.
|
|
Associated procedures
In the 4 patients with associated aortic valve endocarditis, the aortic valve was replaced with a cryopreserved aortic homograft using the freestanding technique. In the patient with associated pulmonary valve endocarditis, the pulmonary valve was excised and replaced by a monocusp valve created from the pulmonary artery wall [4]. All patients completed a 4-week postoperative course of antibiotic treatment.
|
Results
|
|---|
All patients were weaned from cardiopulmonary bypass uneventfully. Intraoperative transesophageal echocardiography demonstrated no (n = 3) or minimal (n = 4) tricuspid regurgitation. No early deaths are reported. All patients were discharged from hospital after 10 to 14 days. Follow-up was performed on all patients from 9 to 46 months, with a mean of 30 months. One late death (16 months) after reoperation due to recurrent aortic endocarditis without recurrent tricuspid endocarditis is reported. All remaining patients were in New York Heart Association functional class I and in sinus rhythm. Two-dimensional transthoracic echocardiography demonstrated excellent mobility of the homograft and good coaptation with the septal leaflet. The median gradient was 4 mm Hg and minimal regurgitation was present in 4 patients. No reoperation was performed during the follow-up period due to recurrent tricuspid endocarditis. Follow-up relative to surgical treatment is presented in Table 2.
|
Comment
|
|---|
Tricuspid endocarditis in patients who abuse intravenous drugs is becoming a frequent problem. Persistence of sepsis and congestive heart failure have been the two classic indications for surgical treatment of tricuspid endocarditis [1]. The 7 patients we report are in this category and were referred to our hospital at a stage where the level of destruction of their valves precluded repair. This raises three questions: What is the correct timing for operation in tricuspid endocarditis? What are the surgical options relative to the evolution of the lesions? and If a homograft is indicated, what technique of implantation should be used?
Concerning the timing of operation in the setting of valve endocarditis, our group has advocated the strategy that consists of operating at an early stage in the evolution of the infectious process [9]. The rationale for this approach is based on the fact that a repair can only be undertaken with a good chance of success if it is performed before advanced destruction of the valvular apparatus. Rather than waiting for the classic criteria based on deterioration of clinical status, the indication for operation should be determined at an earlier stage by the absence of a rapid response of the lesions to antibiotic therapy. Recurrent infection is the dominant problem in patients with tricuspid endocarditis associated with intravenous drug abuse. Replacement of the tricuspid valve by a prosthesis in this situation has the double disadvantage of inability to control the infectious process and a risk of reinfection in the future [11]. In the past, when surgeons were not familiar with the repair techniques, tricuspid valve excision without replacement was advocated [2, 3]. This procedure eradicates the site of infection and eliminates the target for recurrent infections. It is also a simple and expeditious procedure. However, because tricuspidectomy is not always well tolerated hemodynamically, some patients require prosthetic replacement later. For this reason tricuspid valvuloplasty should be preferred as a primary indication. Infection of the tricuspid valve affects most frequently the anterior leaflet of the tricuspid valve, sometimes the posterior leaflet, but rarely the septal leaflet. The infectious process presents in two forms: productive endocarditis with vegetations, which is associated with no or mild regurgitation, and destructive endocarditis, which causes regurgitation and eventually septic pulmonary embolization. In the first form, vegectomy and resection of the base of implantation of the vegetation on the leaflet followed by pericardial patch repair is recommended [12]. In the second form, feasibility of repair is conditioned by the degree of destruction of the subvalvular apparatus of the anterior leaflet. When more than half of the marginal chords of the anterior leaflet are affected, the predictability of repair is seriously compromised. In fact, when the marginal cords of the anterior leaflet have been removed, the possibility of transferring techniques are limited to the basal chords of the anterior leaflet. This is due to the fact that the chords of the posterior leaflet are not in the correct orientation and those of the septal leaflet are usually unavailable. This situation occurred in all our patients and explains our decision to use a homograft technique. The choice of performing a partial rather than a total replacement of the tricuspid valve by a homograft is based principally on the amount of resected tissue. In this series, all patients underwent resection of the anterior and the posterior leaflet of the tricuspid valve, which corresponds to maximum resection in tricuspid endocarditis, as the septal leaflet is rarely affected by the infection. Leaving in place the native septal leaflet has the advantage of requiring no suture in the region of the tricuspid annulus corresponding to conduction tissue. The use of a mitral rather than a tricuspid homograft in the tricuspid position is explained by the fact that mitral valve tissue is easier to work with. The quality of the leaflet tissue is better and the subvalvular apparatus of the mitral valve has a more predictable anatomy compared to that of the tricuspid valve. However, placing the mitral valve in a heterotopic situation requires certain technical adaptations [13, 14]. For total mitral homograft replacement of the tricuspid valve, it has been proposed that the homograft be placed in an antianatomic position with the anterior mitral leaflet attached to the septum [15]. It is our belief that in this configuration, systolic anterior motion of this leaflet may produce obstruction of the pulmonary outflow tract. We believe that partial homograft replacement should be performed in the anatomic position with the anterior leaflet opposite the septum, which in our patients was also justified by the fact that the septal leaflet was not excised [16]. Careful and accurate implantation of the papillary muscle is the most crucial step for accurate coaptation of the valve leaflets [17, 18]. In most reports concerning replacement of the tricuspid valve with homograft material, the papillary muscles of the homograft were placed first in the right ventricle at the site corresponding to the tricuspid papillary muscles, followed by the suturing of the leaflet tissue to the tricuspid annulus [16, 17, 19, 20]. Miyagishima and colleagues [21] reported on 5 patients who underwent mitral homograft replacement of the tricuspid valve. The homograft was implanted with the anterior leaflet orientated to the septum and the papillary muscles exteriorized and sutured to the right ventricular wall. Recently, Hvass and associates [22] performed a mitral homograft implantation in the tricuspid position with a buttonhole technique for both homograft papillary muscles.
In our patients, we used a different technique characterized by the fact that the leaflets of the homograft were partially sutured first followed by papillary muscle implantation. This permitted, once the leaflet was in place, to pull its margin against the native septal leaflet in the systolic position and to determine the site of implantation of the papillary muscle on the free wall of the right ventricle, which did not correspond to the site of the native tricuspid papillary muscles. We assumed that the form of the empty right ventricle, with gentle traction on the free wall when the tricuspid valve was exposed, corresponds to its shape in systole. This technique permits more flexibility for placing the mitral valve in the right ventricle when considering that the anatomy of the subvalvular apparatus of the mitral and tricuspid valve are quite different. Finally, the use of a rigid tricuspid Carpentier ring was justified for the following reasons: it reinforces the repair, restores the orifice to a normal tricuspid valve configuration, and adjusts the size of the orifice to the size of the homograft.
In conclusion, we describe a technique that can be considered an extension of the already existing reconstructive approaches of the tricuspid valve for right-sided endocarditis. If, after adequate excision of all infected tissue, the septal leaflet of the tricuspid valve remains intact, the anterior leaflet and posterior commissure of a mitral homograft may be inserted forming a reliable, competent infection-resistant trileaflet configuration.
|
References
|
|---|
-
Chang P., Ogilby J.D., Segal B. Tricuspid valve endocarditis. Am Heart J 1989;117:1140-1146.[Medline]
-
Arbulu A., Thomas N.W., Chiscano A., Wilson R.F. Total tricuspid valvulectomy without replacement in the treatment of Pseudomonas endocarditis. Surg Forum 1971;22:62-64.
-
Arbulu A., Holmes R.J., Asfaw I. Tricuspid valvulectomy without replacement: twenty years of experience. J Thorac Cardiovasc Surg 1991;102:917-922.[Abstract]
-
Couetil J.P., Berrebi A., Ferdinand F.D., et al. New approach for reconstruction of the pulmonary outflow tract during the Ross procedure. Circulation 1998;98(19 suppl 2):368-371.
-
Carpentier A., Deloche A., Hanania G., et al. Surgical management of acquired tricuspid valve disease. J Thorac Cardiovasc Surg 1974;67:53-65.[Medline]
-
Carpentier A. Cardiac valve surgery—the "French Correction". J Thorac Cardiovasc Surg 1983;86:323-337.[Medline]
-
Yee E.S., Ullyot D.J. Reparative approach for right-sided endocarditis. Operative consideration and results of valvulplasty. J Thorac Cardiovasc Surg 1988;96:133-140.[Abstract]
-
Allen M.D., Slachman F., Eddy C., Cohen D., Otto C., Pearlman A. Tricuspid valve repair for tricuspid valve endocarditis: tricuspid valve recycling. Ann Thorac Surg 1991;51:593-598.[Abstract/Free Full Text]
-
Dreyfus G., Serraf A., Jebara V.A., et al. Valve repair in acute endocarditis. Ann Thorac Surg 1990;49:706-713.[Abstract/Free Full Text]
-
Acar C., Tolan M., Berrebi A., et al. Homograft replacement of the mitral valve. J Thorac Cardiovasc Surg 1996;111:367-380.[Abstract/Free Full Text]
-
Stern H.S., Sisto D.A., Stom J.A., Soeiro J.A., Jones S.R., Frater F.W.M. Immediate tricuspid valve replacement for endocarditis. Indications and results. J Thorac Cardiovasc Surg 1986;91:163-167.[Abstract]
-
Jagger J.D., McCaughn B.C., Pawsey C.G.K. Tricuspid valve endocarditis cured by excision of a single vegetation. Am Heat J 1986;112:626-627.
-
Revuelta J.M., Bernal J.M., Rabasa J.M. Transvalvular technique for implantation of a mitral homograft. J Thorac Cardiovasc Surg 1996;111:281-282.[Free Full Text]
-
Bernal J.M., Rabasa J.M., Cagigas J.C., Val F., Revuelta J.M. Behavior of mitral allografts in the tricuspid position in the growing sheep model. Ann Thorac Surg 1998;65:1326-1330.[Abstract/Free Full Text]
-
Acar C., Iung B., Cormier B., et al. Double mitral homograft for recurrent bacterial endocarditis of the mitral and tricuspid valves. J Heart Valve Dis 1994;3:470-472.[Medline]
-
Pomar J.L., Mestres C.A., Pare J.C., Miro J.M. Management of persistent tricuspid endocarditis with transplantation of cryopreservd mitral homografts. J Thorac Cardiovasc Surg 1994;107:1460-1463.[Abstract/Free Full Text]
-
Revuelta J.M., Bernal J.M., Rabasa J.M. Partial homograft replacement of mitral valve. Lancet 1994;344:514.[Medline]
-
Cosgrove D.M. Mitral homograft for tricuspid valve replacement. J Heart Valve Dis 1993;2:124.[Medline]
-
Ramsheyi A., D’Attellis N., Le Lostec Z., Fegueux S., Acar C. Partial mitral homograft for tricuspid valve repair. Ann Thorac Surg 1997;64:1486-1488.[Abstract/Free Full Text]
-
Di Summa M., Donegani E., Zattera G., Pansini S., Morea M. Successful orthotopic transplantation of a fresh tricuspid valve homograft in human. Ann Thorac Surg 1993;56:1407-1408.[Medline]
-
Miyagishima R.T., Brumwell M.L., Jamieson E.W.R., Munt B.I. Tricuspid valve replacement using a cryopreserved mitral homograft. Surgical technique and initial results. J Heart Valve Dis 2000;9:805-809.[Medline]
-
Hvass U., Baron F., Fourchy D., Pansard Y. Mitral homografts for total tricuspid valve replacement: comparison of two techniques. J Thorac Cardiovasc Surg 2001;121:592-594.[Free Full Text]
This article has been cited by other articles:
|
|
|
|
 
J. G. Byrne, K. Rezai, J. A. Sanchez, R. A. Bernstein, E. Okum, M. Leacche, J. M. Balaguer, S. Prabhakaran, C. R. Bridges, and R. S. D. Higgins
Surgical Management of Endocarditis: The Society of Thoracic Surgeons Clinical Practice Guideline
Ann. Thorac. Surg.,
June 1, 2011;
91(6):
2012 - 2019.
[Full Text]
[PDF]
|
|
|
|
|
|
|
R. Capoun, M. Thomas, M. Caputo, and G. Asimakopoulos
Surgical treatment of tricuspid valve endocarditis: a single-centre experience
Perfusion,
May 1, 2010;
25(3):
169 - 173.
[Abstract]
[PDF]
|
|
|
|
|
|
|
B. M.S. Shrestha, S. Fukushima, M. Vrtik, I. H. Chong, L. Sparks, H. Jalali, and P. G. Pohlner
Partial Replacement of Tricuspid Valve Using Cryopreserved Homograft
Ann. Thorac. Surg.,
April 1, 2010;
89(4):
1187 - 1194.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
M. Musci, H. Siniawski, M. Pasic, O. Grauhan, Y. Weng, R. Meyer, C. A. Yankah, and R. Hetzer
Surgical treatment of right-sided active infective endocarditis with or without involvement of the left heart: 20-year single center experience
Eur J Cardiothorac Surg,
July 1, 2007;
32(1):
118 - 125.
[Abstract]
[Full Text]
[PDF]
|
|
|
Top
Abstract
Introduction
