Ann Thorac Surg 2005;80:721-723
© 2005 The Society of Thoracic Surgeons
Case report
Sliding Plasty Using the Triple-Orifice Technique for Tricuspid Endocarditis
Hideki Sasaki, MD
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,
Kenji Ihashi, MD,
Kazunori Ishikawa, MD
Department of Cardiovascular Surgery, Hoshi General Hospital, Koriyama City, Fukushima, Japan
Accepted for publication February 3, 2004.
* Address reprint requests to Dr Sasaki, Department of Cardiovascular Surgery, Hoshi General Hospital, 2-1-16, Omachi, Koriyama City, Fukushima 963-8501, Japan (Email: h-sasaki{at}mtc.biglobe.ne.jp).
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Abstract
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A 29-year-old male with tricuspid endocarditis related to a residual ventricular septal defect was studied. A large vegetation was resected along with partial excision of the valve. The tricuspid valve was reconstructed using a single-stitch triple-orifice technique. No regurgitation or stenosis was detected at the valve 6 months after surgery.
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Introduction
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During surgery for tricuspid endocarditis, valve replacement or valvectomy is a common procedure. Valvuloplasty is possible depending on the lesion and the area of the valve affected. We present a patient with active endocarditis in whom we performed tricuspid valvuloplasty after excision of a vegetation on the tricuspid valve.
A 29-year-old male who complained of high fever (40°C) and general fatigue was admitted to our hospital. He had undergone ventricular septal defect (VSD) closure in another hospital 27 years earlier. Transthoracic echocardiography revealed no residual ventricular septal defects (VSD) or vegetation. His symptoms did not improve despite the administration of antibiotics. Blood culture confirmed a Staphylococcus epidermidis infection. Ten days after admission transesophageal echocardiography indicated an abnormal 3 x 2 cm mass at the tricuspid valve (Fig 1) and severe tricuspid regurgitation. Multiple pulmonary abscesses were detected by chest-computed tomography. Because of these circumstances it was decided that surgery was required.
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Fig 1. Transesophageal echocardiography indicated an abnormal mass at the tricuspid valve. (RA = right atrium; RV = right ventricle.)
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A median sternotomy was executed through which an arterial cannula was placed in the ascending aorta along with bicaval drainage. Cardiopulmonary bypass (CPB) was established. The aorta was clamped and the heart was arrested with antegrade blood cardioplegia. The tricuspid valve was exposed and a large vegetation involving the anterior and septal leaflets was indicated (Fig 2A). After removal of the vegetation, shunt flow from the residual VSD was detected at the perimembranous area and was closed directly. Removal of the vegetation resulted in the loss of one-third of the anterior leaflet. The remaining two-thirds of the residual anterior leaflet was detached and reattached by use of the sliding plasty technique (Fig 2B). A new commissure between the anterior and septal leaflets was created. Coaptation was incomplete because of a centrally located wide opening between the leaflets. The tricuspid valve was repaired by stitching together the middle point of the free edges of each of the tricuspid leaflets with one 4-0 Prolene suture (Ethicon, Somerville, NJ) (Fig 2C). Saline was injected into the right ventricle to test valvular competence and the resulting tricuspid regurgitation was trivial.
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Fig 2. Operative procedures: (A) a large vegetation is present between the anterior and septal leaflets of the tricuspid valve, (B) sliding plasty technique is applied to the detached anterior leaflet, and (C) the middle points of the free edges of the tricuspid leaflets are sutured together.
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The patient was weaned from CPB without difficulty. Central venous pressure was 10 cm H2O. No transvalvular gradient and only trivial regurgitation were detected by two-dimensional transesophageal echocardiography at discharge and also at 6 months postoperatively (Fig 3). Cefazolin (2 g/d) was administered for 4 weeks postoperatively and no recurrent symptoms of infective endocarditis (IE) were observed.
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Fig 3. No transvalvular gradient and only trivial regurgitation were detected by two-dimensional transesophageal echocardiography 6 months postoperatively. (RA = right atrium; RV = right ventricle).
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Comment
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Right-sided IE, in comparison to left-sided endocarditis, was reported to be cured more often by medication [1]. However IE can be hazardous to the patient with congenital heart disease and sometimes requires surgery. IE occurs most often in patients with VSD, patent ductus arteriosus, or tetralogy of Fallot. In VSD turbulence through the defect leads to IE. Although medication is the first treatment choice in right-sided IE, even if IE is inactive, surgery is recommended for patients resistant to antibiotics or for patients who exhibit progressive heart failure, repetitive pulmonary embolism, or a giant vegetation.
There are three surgical procedures available for tricuspid endocarditis: tricuspid valvectomy without prosthetic valve replacement, tricuspid valvuloplasty with partial excision of the tricuspid valve, and tricuspid valvectomy with prosthetic valve replacement. Arbulu and associates [2] reported excellent patient outcome after tricuspid valvectomy without prosthetic valve replacement, but right heart failure was a complication in 10%–30% of their patients who subsequently required valve replacement.
Although valve replacement was an option we wanted to avoid placing a prosthesis in the infected area in our patient so we performed valvuloplasty. The vegetation in our patient involved both the anterior and septal leaflets. After removal of the vegetation the anterior leaflet decreased to approximately two-thirds the size of the original. Thus we had to reconstruct a new commissure between the anterior and septal leaflets and also to coapt the three leaflets. We used the sliding plasty technique for annuloplasty and the edge-to-edge technique that Fucci and associates [3] applied to the mitral valve to resolve the central regurgitation. Because the anterior leaflet decreased in size by one-third, valvuloplasty seemed difficult. However the sliding plasty was an effective technique for reattaching the residual valve to the annulus. Annular dilatation was not present because the tricuspid regurgitation occurred acutely and was caused by the vegetation and deformation of the valve. Right ventricular enlargement did not occur so we did not have to use an artificial valvular ring. Because the sliding plasty was applied to the anterior leaflet only the overall valve geometry changed. Regurgitation would not have decreased even if we had performed annuloplasty with an artificial valvular ring.
Our method indicated the advantage of not introducing a prosthesis into the infected area. We were concerned with regard to tricuspid stenosis because of the large defect of the anterior leaflet. However central venous pressure after the patient was weaned from CPB was 10 cm H2O and postoperative hepatic failure and peripheral edema did not occur indicating that tricuspid valve function was preserved. Alfieri and associates [4] recently performed valvuloplasty for traumatic tricuspid regurgitation with chordal rupture employing the same leaflet suturing technique we report herein. We believe this technique to be simple and effective not only for traumatic tricuspid regurgitation but also in cases of a defective valve.
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References
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- Chan P, Ogilby JD, Segal B. Tricuspid valve endocarditis Am Heart J 1989;117:1140-1146.[Medline]
- Arbulu A, Asfaw I. Tricuspid valvulectomy without prosthetic valve replacementTen years of clinical experience. J Thorac Cardiovasc Surg 1981;82:684-691.[Medline]
- Fucci C, Sandrelli L, Pardini A, et al. Improved results with mitral valve repair using new surgical techniques Eur J Cardiothorac Surg 1995;9:621-627.[Abstract]
- Alfieri O, De Bonis M, Lapenna E, et al. The "clover technique" as a novel approach for correction of post-traumatic tricuspid regurgitation J Thorac Cardiovasc Surg 2003;126:75-79.[Abstract/Free Full Text]
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Abstract
Introduction
