Ann Thorac Surg 2003;75:605-606
© 2003 The Society of Thoracic Surgeons
How to do it
Edge-to-edge tricuspid repair for redeveloped valve incompetence after DeVega’s annuloplasty
Evaristo Castedo, MDa*,
Alfonso Cañas, MDa,
Ruben A. Cabo, MDa,
Raul Burgos, MDa,
Juan Ugarte, MDa
a Department of Cardiothoracic Surgery, Hospital Clinica Puerta de Hierro, Universidad Autonoma de Madrid, Madrid, Spain
Accepted for publication July 31, 2002.
* Address reprint requests to Dr Castedo, Department of Cardiothoracic Surgery, Hospital Clinica Puerta de Hierro, C, San Martín de Porres, 4. 28035 Madrid, Spain
e-mail: evaristocm{at}terra.es
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Abstract
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"Edge-to-edge" technique is a well-accepted procedure with excellent results for correction of mitral insufficiency. We describe a simple edge-to-edge combined with bicuspidalization repair method that was successfully applied in 2 patients for the treatment of redeveloped functional tricuspid regurgitation after previous annuloplasty. Significant improvement in symptoms and echocardiographic results were achieved.
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Introduction
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Tricuspid regurgitation (TR) is a very common valve disease, usually secondary to pulmonary hypertension due to left-sided heart valve lesions. Surgical management of TR is often difficult, especially when it persists after a previous valve repair procedure. We describe a technique for preserving native tricuspid valve in cases of functional TR after previous annuloplasty.
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Technique
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When facing a TR that has developed after a previous repair procedure in the context of left-sided rheumatic heart valve disease, we first rule out the existence of extensive organic tricuspid involvement. If severe postinflammatory changes are present, which includes leaflet or chordal thickening and retraction or chordal fusion, tricuspid valve replacement by a prosthesis is preferred. Otherwise, if annulus enlargement is the only apparent reason for TR, we try to achieve a competent native valve by the combination of a "double orifice" technique with tricuspid bicuspidalization. The procedure is as follows: First, a bicuspid right atrioventricular valve is obtained by plicating the posterior leaflet with a pledgeted 2-0 TI-CRON (Sherwood Medical, St. Louis, MO) running suture at the level of the annulus (Fig 1a).
An edge-to-edge approximation of the septal tricuspid leaflet to the newly created anteroposterior leaflet is then performed, using a U stitch of 4-0 polypropylene suture, according to mitral valve repair described by Fucci and colleagues [1]. This edge-to-edge suture is placed in the midpoint of both leaflets (Fig 1b).
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Fig 1. (a) Tricuspid valve bicuspidalization is accomplished by plicating the posterior leaflet (P) with a pledgeted annular running suture. (b) Edge-to-edge approximation (arrowhead) of the septal tricuspid leaflet (S) to the new created anteroposterior leaflet (A) leads to a double valve orifice.
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We have successfully performed this technique in 2 patients who presented with a severe functional TR after a previous tricuspid valve repair. Both patients had undergone mitral valve replacement with a mechanical prosthesis and a DeVega’s tricuspid annuloplasty due to rheumatic mitral valve disease 15 and 20 years ago, respectively. No significant TR was detected by echocardiographic studies performed within the first 10 years of follow-up, but afterwards TR and pulmonary hypertension rapidly progressed. Indications for reoperation were severe TR with incapacitating symptoms of right ventricular failure, associated, in 1 patient, with severe aortic regurgitation that required aortic valve replacement, and in the other patient with severe mitral periprosthetic leak that was resutured. Absence of central coaptation of the leaflets due to severe tethering was detected intraoperatively by the injection of cold saline solution through a pigtail catheter passing from the main pulmonary artery into the right ventricle. Because repeated saline injection and intraoperative echocardiography performed after the procedure disclosed no residual significant TR, we judged it unnecessary to implant a prosthetic ring to reinforce the annulus. At 6 months of follow-up, the patients remain asymptomatic. The efficacy of the annuloplasty procedure was evaluated by pulsed Doppler echocardiography, which showed a residual TR of grade 1/4 in both patients. The tricuspid annulus diameter and TR area were reduced from 52.8 ± 0.6 mm to 28.8 ± 0.8 mm and 800 ± 28 mm2 to 126 ± 5 mm2, respectively.
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Comment
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Rheumatic heart disease is still highly prevalent in our country and the most common cause of TR. Rheumatic TR usually results from functional impairment of the valve, secondary to pulmonary hypertension and right ventricular enlargement. Clinical manifestations of right heart failure are frequently present in these patients and must be considered a surgical indication. Because annular dilatation is the cause of valve incompetence in the majority of patients, unless extensive organic valve involvement is present, tricuspid valve repair is preferred to prosthetic replacement, even in cases of recurrence of TR after a previous repair.
Among the several techniques described for tricuspid valve repair, DeVega’s semicircular annuloplasty is the most commonly used in our country and many modifications of this procedure have been reported with excellent results [2]. Nevertheless, persistence or recurrence of valve incompetence after DeVega’s annuloplasty may account for 8% of patients during midterm follow-up [3]. Nearly always, persisting or redeveloped TR after repair is associated with recurrent mitro-aortic disease or developed severe pulmonary hypertension that leads to progression of right ventricular failure and annular dilatation. Both conditions were evident in our patients and the most likely causes of TR.
The edge-to-edge technique, as described by Fucci and colleagues [1], has been applied for the correction of mitral regurgitation with a very low operative and late mortality and a high percentage of patients being free from reoperation. With this method, the free edge of the prolapsing portion of the anterior leaflet is anchored to the facing edge of the posterior leaflet, creating a double orifice mitral valve. This group of investigators has also successfully applied this technique for the treatment of traumatic TR [4]. Mantovani and associates [5] have reported a patient with an effective edge-to-edge tricuspid valve repair combined with chordae shortening, implantation of a ring, and atrial defect closure for the treatment of a congenital familiar TR.
Bicuspidalization annuloplasty, described by Kay and colleagues [6], is a simple technique with good late results, based on the conversion of the tricuspid valve into a bicuspid valve by making sutures to obliterate most of the posterior annulus.
We describe a method for the correction of TR, which is a combination of two well-established reparative techniques: tricuspid bicuspidalization, achieved by posterior leaflet plication, and the double valve orifice repair, obtained by approximation of the septal and anteroposterior leaflets. We believe that application of edge-to-edge repair should not be restricted to mitral insufficiency and congenital or traumatic TR. If combined with bicuspidalization, it can be effective in dealing with acquired functional TR, especially in patients with great annulus diameter in which annuloplasty was previously performed, who otherwise would be candidates for valve replacement.
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References
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- Fucci C., Sandrelli L., Pardini A., Torracca L., Ferrari M., Alfieri O. Improved results with mitral valve repair using new surgical techniques. Eur J Cardiothorac Surg 1995;9:621-627.[Abstract/Free Full Text]
- De Vega N.G. La anuloplastia selectiva, regulable y permanente: una técnica original para el tratamiento de la insuficiencia tricúspide. Rev Esp Cardiol 1972;25:555-556.[Medline]
- Abe T., Tukamoto M., Yanagiya M., Morikawa M., Watanabe N., Komatsu S. De Vega’s annuloplasty for acquired tricuspid disease: early and late results in 110 patients. Ann Thorac Surg 1989;48:670-676.[Abstract/Free Full Text]
- Maisano F., Lorusso R., Sandrelli L., et al. Valve repair for traumatic tricuspid regurgitation. Eur J Cardiothorac Surg 1996;10:867-873.[Abstract/Free Full Text]
- Mantovani V., Grossi C., Ferrarese S., Sala A. Edge-to-edge repair of congenital familiar tricuspid regurgitation: case report. J Heart Valve Dis 2000;9:641-643.[Medline]
- Kay J.H., Maselli-Campagna G., Tsuji H.K. Surgical treatment of tricuspid insufficiency. Ann Surg 1965;162:53-58.[Medline]
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Abstract
Introduction
