Ann Thorac Surg 2007;84:309-311
© 2007 The Society of Thoracic Surgeons
How To Do It
Off-Pump Tricuspid Valve Replacement for Severe Infective Endocarditis
Kun-Kuang Lee, MD,
Hsi-Yu Yu, MD,
Yih-Sharng Chen, MD,
Nai-Hsin Chi, MD*,
Chung-I Chang, MD,
Shoei-Shen Wang, MD
Department of Surgery, National Taiwan University Hospital, and National Taiwan University College of Medicine, Taipei, Taiwan
Accepted for publication October 16, 2006.
* Address correspondence to Dr Chi, Department of Surgery, National Taiwan University Hospital, 7 Chung-Shan South Road, Taipei, 100, Taiwan (Email: chinaihsin{at}gmail.com).
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Abstract
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A 30-year-old man who is a heroin addict was diagnosed with uncontrolled tricuspid valve endocarditis and repeated lung abscesses. He underwent tricuspid valvectomy for the endocarditis. After surgery the patient had severe tricuspid regurgitation and hypoxemia develop. Due to severe tricuspid regurgitation-induced ventricular distension and persistent low cardiac output, reimplantation of the tricuspid valve was planned for 2 weeks after the first operation. To avoid lung injury caused by the cardiopulmonary bypass and to preserve right ventricular function, a self-made superior and inferior vena cava shunt was connected to the pulmonary artery. The tricuspid valve was implanted without cardiopulmonary bypass.
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Introduction
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Cardiac surgeons may encounter patients with right-sided endocarditis, sepsis, and despite intensive antibiotics treatment, destroyed lung function. Open heart surgery for cardiopulmonary bypass for right-sided lesions may be necessary. However, the bypass has an increased risk of inflammatory reactions and deteriorating lung function. Furthermore, during cardiopulmonary bypass, the lungs remain relatively ischemic as a result of the direction of venous blood returning through the extracorporeal perfusion circuit [1, 2]. To preserve right ventricular function, prevent additional lung injury, and minimize inflammatory responses, a novel procedure was used to replace the infective tricuspid valve without using cardiopulmonary bypass.
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Technique
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A 30-year-old man who is a heroin abuser had uncontrolled tricuspid valve endocarditis, recurrent lung abscess, and cavitations (Figs 1a,
1b). At another institution, the patient received tricuspid valvectomy during which all vegetations were removed for infection control. Postoperatively he had severe tricuspid regurgitation and hypoxemia develop, and he was transferred to our institute for additional treatment. Venoarterial extracorporeal membrane oxygenation was set up and then it was changed to venovenous extracorporeal membrane oxygenation. Due to severe tricuspid regurgitation-induced ventricular distention and persistent low cardiac output, reimplantation of the tricuspid valve was planned for 2 weeks after the first operation. To eliminate cardiopulmonary bypass-related lung injury and to preserve right ventricular function, a self-made superior vena cava inferior vena cava shunt was applied to the pulmonary artery (Fig 2). Without cardiopulmonary bypass, the right atrium was opened and the tricuspid valve was replaced with a stentless porcine prosthesis under a beating heart (Fig 1c). The patient withstood the procedure well and venovenous extracorporeal membrane oxygenation was removed during surgery.
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Fig 1. (a) Chest roentgenogram demonstrated infiltration and cavitations over bilateral lung fields. (b) Chest computed tomographic scan revealed bilateral destroyed lung with multiple cavitations. (c) Postoperative magnetic resonance imaging; the arrow indicates the stentless xenograft in the tricuspid position.
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Preoperative Hemodynamics
Preoperatively, the patient’s systolic pulmonary artery pressure was around 35 mm Hg due to severe free tricuspid regurgitation. Central venous pressure and waveform contour were the same as those for the pulmonary artery. The patient had destroyed lungs and was easily desaturated (SaO2 < 80% under PIO
2 100%), so he could not be weaned from venovenous extracorporeal membrane oxygenation.
Description
The shunt was constructed using a 24-French angled-tip venous cannula (Medtronic, Minneapolis, MN) for the superior vena cava, inferior vena cava, and pulmonary artery. Prior to the procedure the patient was administered 2 mg/kg heparin. The superior vena cava was connected to the pulmonary artery with the shunt first and then it was snared to the superior vena cava. During that period, the patient’s blood pressure and saturation did not change. Then the inferior vena cava cannula was inserted, snared to the inferior vena cava, and connected to the circuit (Fig 2). The patient was then placed in Trendelenberg position, and with his left side downward by tilting the operative table; the patient’s systolic blood pressure was maintained at > 85 mm Hg. After opening the right atrium, a retrograde catheter (DLP RCSP Cannulae with Auto-Inflate Cuff [Medtronic]) was inserted into the coronary sinus to introduce some blood into the circuit. The remaining blood was collected by a cell saver. Inserting a Medtronic Freestyle stentless porcine valve (Medtronic) in the tricuspid position took 18 minutes (Fig 1c).
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Comment
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Tricuspid valve infective endocarditis is often treated medically with good outcomes. However, persistent infection may cause the presence of vegetation that may be difficult to eradicate. Such a situation indicates surgical treatment [3]. Surgical options are vegetectomy, valvulectomy, valve repair, and valve replacement using cardiopulmonary bypass [3–5]. However, in this case in which the patient was in critical condition, cardiopulmonary bypass can further reduce the poor function of the septic lung. Raman and colleagues [6] presented their results of tricuspid valve endocarditis vegetectomy under inflow occlusion without cardiopulmonary bypass. In that clinical study there were no deaths and inflow occlusion time did not exceed 2 minutes (range, between 45 seconds and 2 minutes). All patients achieved resolution of sepsis and improved respiratory status within 48 hours [6]. We believe inflow occlusion method is a procedure that avoids bypass inflammatory reactions. The patient in this report had undergone tricuspid valvectomy and had severe right-sided heart failure and septic lung. The patient was scheduled to receive a porcine tricuspid valve; however, inflow occlusion was not adequate as tricuspid valve replacement requires more than 2 minutes. Therefore, a novel circuit using the concept of total cavopulmonary connection was designed [7]. The circuit allows surgeons to operate in a relatively bloodless right heart under a beating heart without cardiopulmonary bypass, thereby avoiding lung injury and systemic inflammation associated with cardiopulmonary bypass. The patient was discharged smoothly after 30 days of antibiotic treatment.
In conclusion, using cardiopulmonary bypass for right-sided open heart surgery is the standard method and provides a routine, safe, and reliable environment for surgeons. However, in some specific situations, patients may experience complications associated with the bypass. This report describes a novel method as an alternative for a patient who can not tolerate cardiopulmonary bypass.
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References
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- Asimakopoulos G, Smith PL, Ratnatunga CP, Taylor KM. Lung injury and acute respiratory distress syndrome after cardiopulmonary bypass Ann Thorac Surg 1999;68:1107-1115.[Abstract/Free Full Text]
- Carney DE, Lutz CJ, Picone AL, et al. Matrix metalloproteinase inhibitor prevents acute lung injury after cardiopulmonary bypass Circulation 1999;100:400-406.[Abstract/Free Full Text]
- Miro JM, Moreno A, Mestres CA. Infective endocarditis in intravenous drug abusers Curr Infect Dis Rep 2003;5:307-316.[Medline]
- Renzulli A, De Feo M, Carozza A, et al. Surgery for tricuspid valve endocarditis: a selective approach Heart Vessels 1999;14:163-169.[Medline]
- Barbour DJ, Roberts WC. Valve excision only versus valve excision plus replacement for active infective endocarditis involving the tricuspid valve Am J Cardiol 1986;57:475-478.[Medline]
- Raman J, Bellomo R, Shah P. Avoiding the pump in tricuspid valve endocarditis—vegetectomy under inflow occlusion Ann Thorac Cardiovasc Surg 2002;8:350-353.[Medline]
- Szabo G, Buhmann V, Graf A, et al. Ventricular energetics after the Fontan operation: contractility-afterload mismatch J Thorac Cardiovasc Surg 2003;125:1061-1069.[Abstract/Free Full Text]
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Abstract
Introduction
