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Tricuspid Valve Repair for Functional Tricuspid Regurgitation
Tricuspid Valve Repair for Functional Tricuspid Regurgitation A. Marc Gillinov and Delos M. Cosgrove
Tricuspid valve insufficiency can be caused by organic disease of the tricuspid valve (rheumatic disease, endocarditis, carcinoid, and so on); however, most tricuspid regurgitation encountered in clinical practice occurs in patients with chronic left-sided valvular lesions. Ten percent to 50% of patients with severe mitral valve dysfunction have significant tricuspid regurgitation. In this situation, functional tricuspid regurgitation is attributable to pulmonary hypertension and right ventricular d i l a t a t i ~ n .Other ~ factors that contribute to functional tricuspid insufficiency may include right ventricular-tricuspid valve disproportion with compromised function of the tricuspid valve apparatus' and depressed tricuspid annular shortening during systole. It is now generally accepted that moderate to severe functional tricuspid insufficiency should be addressed at the time of correction of left-sided valvular disease.6-8 Several surgical options have been used to treat functional tricuspid insufficiency. These include tricuspid valve replacement, bicuspidalization annuloplasty, DeVega suture annuloplasty, and ring annuloplasty (Carpentier [Baxter Healthcare, Irvine, CAI or Duran [Medtronic, Minneapolis, MN]). The first two options, tricuspid valve replacement and bicuspidalization annuloplasty, provide inferior results and should not be used in the setting of functional tricuspid regurgitation. Both the DeVega annuloplasty and the Carpentier ring annuloplasty provide excellent treatment of functional tricuspid r e g ~ r g i t a t i o n . ~However, >~-~ studies suggest that '3'
134
repair durability is better with the Carpentier annuloplasty, particularly in the setting of severe pulmonary hypertension.6*8Other potential disadvantages of the DeVega annuloplasty include the possibility of complete repair dehiscence from the disruption of a single stitch and obligate semicircular deformation of the tricuspid annulus, which may impair long-term valvular function.6 Drawbacks to the Carpentier ring annuloplasty include increased cost, the introduction of foreign material with the attendant risk of endocarditis, and relative rigidity of the prosthesis, which fixes the annulus in the shape of the ring. Recent advances in understanding the physiology of the tricuspid valve have provided the rationale for the use of a new annuloplasty system to correct functional tricuspid ins~fficiency.~ Computer-based analysis of echocardiographic images of the tricuspid valve shows that the tricuspid annulus is a saddle-shaped structure that has sphincter action, being smaller in systole than in diastole." Anatomic studies show that five sixths of annular dilatation takes place at the base of the anterior and posterior leaflets.6 This understanding of the normal physiology and pathoanatomy of the tricuspid valve led us to use an annuloplasty system that is universally flexible and produces a measured plication of the annulus at the base of the anterior and posterior leaflets. Repair of the tricuspid valve using the flexible Cosgrove-Edwards Annuloplasty System (Baxter Healthcare, Irvine, CA) is described.
Operative Techniques in Thoracic and Cardiovascular Surgery, Vol3, No 2 (May), 1998: pp 134139
135
TRICUSPID VALVE REPAIR
SURGICAL TECHNIQUE
1
Exposure and sizing of the tricuspid valve. After the placement of routine monitoringlines, the patient is intubated with a slngle lumen endotracheal tube, and a transesophageal echo probe is placed. Median sternotomy is performed, and the pericardium is opened to the nght of midline. The nght pericardial edge is sutured to the drapes, elevating the ri&t side of the heart and facilitating subsequent exposure of the mitral and tricuspid valves. The patient is systemically heparhized, and the superior vena cava and inferior vena cava are individually cannulated. Vacuumassisted venous drainage (-50 nun Hg) allows use of two 20F venous cannulae, while providing a dry operative field and avoiding venous air lock. The patient is placed on cardiopulmonary bypass, and the aorta is cross-clamped. After administration of antegrade and retrograde cardioplegia, attention is turned to the correction of left-sided valvular disease. (A) A right atriotomy is then performed, and the tricuspid valve is inspected. In functional tricuspid regurgitation, the valve leaflets usually appear normal and the annulus is dilated. (B) The Carpentier-Edwards sker (Baxter Healtheare) is used to determine the appropriate size of the Cosgrove-Edwards Annuloplasty System. The appropriate size is selected based on the length of the attachment of the septal leaflet; this should correspond to the distance between the notches on the sizer.
136
GILLINOV AND COSGROVE
2
The placement of annuloplasty sutures. Interrupted mattress sutures of 2-0 nonabsorbable multifilament are placed in the tricuspid annulus, beginning at the posteroseptal commissure and extending around the annulus to the anteroseptal commissure. Six to 10 sutures are generally required. The sutures are then passed through the polyester velour band of the annuloplasty ring.
137
TRICUSPID VALVE REPAIR
3
The placement of the annuloplasty ring. (A) The annuloplasty ring is slid into position and the handle is removed from the frame. The sutures are tied sequentially, producing a measured plication of the annulus in the region of greatest dilatation. During tying, the handle remains connected to the frame by a lanyard. (B) When all sutures have been tied, the three sutures on the frame are cut, and the frame is removed from the annuloplasty band by gently pulling the lanyard.
138
GILLINOV AND COSGROVE
4
Completed tricuspid valve annuloplasty. The annuloplasty band is in position. A measured plication of the annulus adjacent to the anterior and posterior leaflets is achieved, and the conduction system is not jeopardized.
5
Correction of functional tricuspid regurgitation. I n functional tricuspid regurgitation, most annular dilatation occurs along the annulus adjacent to the anterior and posterior leaflets. The CosgroveEdwards Annuloplasty System plicates these areas, avoiding suture placement in the region of the septal leaflet.
139
TRICUSPID VALVE REPAIR
COMMENTS
REFERENCES
Since its introduction in 1995, the Cosgrove-Edwards Annuloplasty System has been our primary technique for the correction of functional tricuspid insufficiency. The first 50 patients who received this tricuspid annuloplasty included 21 men and 29 women; mean age was 61 years of age (range, 22 to 83 years). One half of the patients had degenerative left-sided valvular disease, and one half had rheumatic disease. For tricuspid valve repair, annuloplasty sizes ranged from 22 to 34 mm; 84% of patients received annuloplasty bands that were 28 to 32 mm. Intraoperative transesophageal echocardiography showed that the mean degree of tricuspid regurgitation decreased from 2.9 prebypass to 0.7 after annuloplasty. At early follow-up (mean of 6 months), one patient required reoperation for recurrent mitral insufficiency and no patients required reoperation for tricuspid valve dysfunction. There had been no episodes of tricuspid valve endocarditis o r other prosthesisrelated morbidity. Satisfactory correction of functional tricuspid insufficiency can be achieved using several techniques. Advantages of the Cosgrove-Edwards Annuloplasty System include technical ease, avoidance of suturing near the conduction system, measured plication of the areas of greatest dilatation, and universal flexibility that preserves tricuspid valve function. Early results with this technique have been gratifying, and the flexibility of this annuloplasty system may have long-term advantages in the preservation of tricuspid valve function.
1. Kirklin JW, PacXico AD: Surgery for acquired valvular heart disease. N Engl J Med 288:194-199,1973 2. Breyer RH, McClenathan JH, Michaelis LL, et al: Tricuspid regurgitation: A comparison of nonoperative management, tricuspid annuloplasty, and tricuspid valve replacement. J Thorac Cardiovasc Surg 72:867-874,1976 3. Tomio A, Tukamoto M, Yanagiya M, et al: DeVega’s annuloplasty for acquired tricuspid disease: Early and late results in 110 patients. Ann Thorac Surg 48:670-676,1989 4. Starr A: Acquired disease of the tricuspid valve, in Gibbon J (ed): Surgery of the Chest. Philadelphia, PA, Saunders, 1969, pp 770-772 5. Simon R, Oelert H, Borst HG, et al: Influence of mitral valve surgery on tricuspid incompetence concomitant with mitral valve disease. Circulation 62:152-157,1980 (suppl 1) 6. Rivera R, Duran E, Ajuria M: Carpentier’s flexible ring versus DeVega’s annuloplasty. J Thorac Cardiovasc Surg 89: 196-203,1985 7. Duran CMG, Kumar N, Prabhakar G, et al: Vanishing DeVega annuloplasty for functional tricuspid regurgitation. J Thorac Cardiovasc Surg 106:609-613,1993 8. Duran CMG: Tricuspid valve surgery revisited. J Card Surg 9:242-247, 1994 (suppl) 9. McCarthy JF, Cosgrove DM: Tricuspid valve repair with the CosgroveEdwards annuloplasty system. Ann Thorac Surg 64967-268,1997 10. Chandra S, PowellK, Breburda CS, et al: Three dimensional reconstruction (shape and motion) of tricuspid annulus in normals and in patients after tricuspid annuloplasty with a flexible ring, in: Computers in Cardiology. Los Alamedos, CA, IEEE Computers Society Press, 1996, pp 693-696
From the Department of Thoracic and Cardiovascular Surgery, The Cleveland Clinic Foundation, Cleveland, OH. Address reprint requests to Delos M. Cosgrove, MD, Department of Thoracic and Cardiovascular SurgerylF25, The Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH 44195. Copyright 0 1998 by W.B. Saunders Company 1085-5637/98/0302-0006$8.00/0
Tricuspid valve insufficiency can be caused by organic disease of the tricuspid valve (rheumatic disease, endocarditis, carcinoid, and so on); however, most tricuspid regurgitation encountered in clinical practice occurs in patients with chronic left-sided valvular lesions. Ten percent to 50% of patients with severe mitral valve dysfunction have significant tricuspid regurgitation. In this situation, functional tricuspid regurgitation is attributable to pulmonary hypertension and right ventricular d i l a t a t i ~ n .Other ~ factors that contribute to functional tricuspid insufficiency may include right ventricular-tricuspid valve disproportion with compromised function of the tricuspid valve apparatus' and depressed tricuspid annular shortening during systole. It is now generally accepted that moderate to severe functional tricuspid insufficiency should be addressed at the time of correction of left-sided valvular disease.6-8 Several surgical options have been used to treat functional tricuspid insufficiency. These include tricuspid valve replacement, bicuspidalization annuloplasty, DeVega suture annuloplasty, and ring annuloplasty (Carpentier [Baxter Healthcare, Irvine, CAI or Duran [Medtronic, Minneapolis, MN]). The first two options, tricuspid valve replacement and bicuspidalization annuloplasty, provide inferior results and should not be used in the setting of functional tricuspid regurgitation. Both the DeVega annuloplasty and the Carpentier ring annuloplasty provide excellent treatment of functional tricuspid r e g ~ r g i t a t i o n . ~However, >~-~ studies suggest that '3'
134
repair durability is better with the Carpentier annuloplasty, particularly in the setting of severe pulmonary hypertension.6*8Other potential disadvantages of the DeVega annuloplasty include the possibility of complete repair dehiscence from the disruption of a single stitch and obligate semicircular deformation of the tricuspid annulus, which may impair long-term valvular function.6 Drawbacks to the Carpentier ring annuloplasty include increased cost, the introduction of foreign material with the attendant risk of endocarditis, and relative rigidity of the prosthesis, which fixes the annulus in the shape of the ring. Recent advances in understanding the physiology of the tricuspid valve have provided the rationale for the use of a new annuloplasty system to correct functional tricuspid ins~fficiency.~ Computer-based analysis of echocardiographic images of the tricuspid valve shows that the tricuspid annulus is a saddle-shaped structure that has sphincter action, being smaller in systole than in diastole." Anatomic studies show that five sixths of annular dilatation takes place at the base of the anterior and posterior leaflets.6 This understanding of the normal physiology and pathoanatomy of the tricuspid valve led us to use an annuloplasty system that is universally flexible and produces a measured plication of the annulus at the base of the anterior and posterior leaflets. Repair of the tricuspid valve using the flexible Cosgrove-Edwards Annuloplasty System (Baxter Healthcare, Irvine, CA) is described.
Operative Techniques in Thoracic and Cardiovascular Surgery, Vol3, No 2 (May), 1998: pp 134139
135
TRICUSPID VALVE REPAIR
SURGICAL TECHNIQUE
1
Exposure and sizing of the tricuspid valve. After the placement of routine monitoringlines, the patient is intubated with a slngle lumen endotracheal tube, and a transesophageal echo probe is placed. Median sternotomy is performed, and the pericardium is opened to the nght of midline. The nght pericardial edge is sutured to the drapes, elevating the ri&t side of the heart and facilitating subsequent exposure of the mitral and tricuspid valves. The patient is systemically heparhized, and the superior vena cava and inferior vena cava are individually cannulated. Vacuumassisted venous drainage (-50 nun Hg) allows use of two 20F venous cannulae, while providing a dry operative field and avoiding venous air lock. The patient is placed on cardiopulmonary bypass, and the aorta is cross-clamped. After administration of antegrade and retrograde cardioplegia, attention is turned to the correction of left-sided valvular disease. (A) A right atriotomy is then performed, and the tricuspid valve is inspected. In functional tricuspid regurgitation, the valve leaflets usually appear normal and the annulus is dilated. (B) The Carpentier-Edwards sker (Baxter Healtheare) is used to determine the appropriate size of the Cosgrove-Edwards Annuloplasty System. The appropriate size is selected based on the length of the attachment of the septal leaflet; this should correspond to the distance between the notches on the sizer.
136
GILLINOV AND COSGROVE
2
The placement of annuloplasty sutures. Interrupted mattress sutures of 2-0 nonabsorbable multifilament are placed in the tricuspid annulus, beginning at the posteroseptal commissure and extending around the annulus to the anteroseptal commissure. Six to 10 sutures are generally required. The sutures are then passed through the polyester velour band of the annuloplasty ring.
137
TRICUSPID VALVE REPAIR
3
The placement of the annuloplasty ring. (A) The annuloplasty ring is slid into position and the handle is removed from the frame. The sutures are tied sequentially, producing a measured plication of the annulus in the region of greatest dilatation. During tying, the handle remains connected to the frame by a lanyard. (B) When all sutures have been tied, the three sutures on the frame are cut, and the frame is removed from the annuloplasty band by gently pulling the lanyard.
138
GILLINOV AND COSGROVE
4
Completed tricuspid valve annuloplasty. The annuloplasty band is in position. A measured plication of the annulus adjacent to the anterior and posterior leaflets is achieved, and the conduction system is not jeopardized.
5
Correction of functional tricuspid regurgitation. I n functional tricuspid regurgitation, most annular dilatation occurs along the annulus adjacent to the anterior and posterior leaflets. The CosgroveEdwards Annuloplasty System plicates these areas, avoiding suture placement in the region of the septal leaflet.
139
TRICUSPID VALVE REPAIR
COMMENTS
REFERENCES
Since its introduction in 1995, the Cosgrove-Edwards Annuloplasty System has been our primary technique for the correction of functional tricuspid insufficiency. The first 50 patients who received this tricuspid annuloplasty included 21 men and 29 women; mean age was 61 years of age (range, 22 to 83 years). One half of the patients had degenerative left-sided valvular disease, and one half had rheumatic disease. For tricuspid valve repair, annuloplasty sizes ranged from 22 to 34 mm; 84% of patients received annuloplasty bands that were 28 to 32 mm. Intraoperative transesophageal echocardiography showed that the mean degree of tricuspid regurgitation decreased from 2.9 prebypass to 0.7 after annuloplasty. At early follow-up (mean of 6 months), one patient required reoperation for recurrent mitral insufficiency and no patients required reoperation for tricuspid valve dysfunction. There had been no episodes of tricuspid valve endocarditis o r other prosthesisrelated morbidity. Satisfactory correction of functional tricuspid insufficiency can be achieved using several techniques. Advantages of the Cosgrove-Edwards Annuloplasty System include technical ease, avoidance of suturing near the conduction system, measured plication of the areas of greatest dilatation, and universal flexibility that preserves tricuspid valve function. Early results with this technique have been gratifying, and the flexibility of this annuloplasty system may have long-term advantages in the preservation of tricuspid valve function.
1. Kirklin JW, PacXico AD: Surgery for acquired valvular heart disease. N Engl J Med 288:194-199,1973 2. Breyer RH, McClenathan JH, Michaelis LL, et al: Tricuspid regurgitation: A comparison of nonoperative management, tricuspid annuloplasty, and tricuspid valve replacement. J Thorac Cardiovasc Surg 72:867-874,1976 3. Tomio A, Tukamoto M, Yanagiya M, et al: DeVega’s annuloplasty for acquired tricuspid disease: Early and late results in 110 patients. Ann Thorac Surg 48:670-676,1989 4. Starr A: Acquired disease of the tricuspid valve, in Gibbon J (ed): Surgery of the Chest. Philadelphia, PA, Saunders, 1969, pp 770-772 5. Simon R, Oelert H, Borst HG, et al: Influence of mitral valve surgery on tricuspid incompetence concomitant with mitral valve disease. Circulation 62:152-157,1980 (suppl 1) 6. Rivera R, Duran E, Ajuria M: Carpentier’s flexible ring versus DeVega’s annuloplasty. J Thorac Cardiovasc Surg 89: 196-203,1985 7. Duran CMG, Kumar N, Prabhakar G, et al: Vanishing DeVega annuloplasty for functional tricuspid regurgitation. J Thorac Cardiovasc Surg 106:609-613,1993 8. Duran CMG: Tricuspid valve surgery revisited. J Card Surg 9:242-247, 1994 (suppl) 9. McCarthy JF, Cosgrove DM: Tricuspid valve repair with the CosgroveEdwards annuloplasty system. Ann Thorac Surg 64967-268,1997 10. Chandra S, PowellK, Breburda CS, et al: Three dimensional reconstruction (shape and motion) of tricuspid annulus in normals and in patients after tricuspid annuloplasty with a flexible ring, in: Computers in Cardiology. Los Alamedos, CA, IEEE Computers Society Press, 1996, pp 693-696
From the Department of Thoracic and Cardiovascular Surgery, The Cleveland Clinic Foundation, Cleveland, OH. Address reprint requests to Delos M. Cosgrove, MD, Department of Thoracic and Cardiovascular SurgerylF25, The Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH 44195. Copyright 0 1998 by W.B. Saunders Company 1085-5637/98/0302-0006$8.00/0