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Complex Tricuspid Valve Repair in Patients With Pacer Defibrillator–Related Tricuspid Regurgitation
HOW TO DO IT
Complex Tricuspid Valve Repair in Patients With Pacer Defibrillator–Related Tricuspid Regurgitation Jaishankar Raman, MMedBS, PhD, Lissa Sugeng, MD, MPH, David T. M. Lai, MD, FRACS, and Valluvan Jeevanandam, MD Department of Cardiovascular and Thoracic Surgery, Rush University Medical Center, Chicago; Department of Medicine, Yale University Medical Center, New Haven, Connecticut; Department of Surgery, National University of Singapore, Singapore; and Department of Surgery, University of Chicago, Chicago, Illinois
Tricuspid valve regurgitation in patients with heart failure or in those undergoing complex cardiac operations is associated with increased morbidity and mortality. We report our results with a technique of repairing the tricuspid valves while retaining the pacer defibrillator lead. Patients had tricuspid valve repairs that included repositioning of the pacer defibrillator
lead, approximation of septal and inferior/posterior leaflets in a modified cleft repair, and implantation of a tricuspid annuloplasty ring. This procedure was performed in more than 42 patients with good success.
T
through a right minithoracotomy, and 5 of these patients had a third or fourth redo procedure. Associated procedures included mitral valve reconstruction in 21 patients, ventricular assist device implantation in 5 patients, coronary artery bypass grafting in 11 patients, left ventricular reconstruction in 8 patients, and aortic valve replacement in 3 patients. Two patients had stand-alone procedures through a right minithoracotomy.
Accepted for publication Aug 26, 2015. Address correspondence to Dr Raman, Department of Cardiovascular and Thoracic Surgery, Rush University Medical Center, 1653 W Congress Pkwy, Chicago, IL 60612; email: [email protected].
Ó 2016 by The Society of Thoracic Surgeons Published by Elsevier
Technique The right atrium was opened with a longitudinal incision and the tricuspid valve was assessed. Stay sutures were placed above the valve annulus in the atrium to display the valve. The mechanism of tricuspid regurgitation was assessed with the heart beating on cardiopulmonary bypass. Figure 1 shows an intraoperative photograph demonstrating the stiff defibrillator lead pushing on the septal leaflet as it traverses the tricuspid annulus. The pacer defibrillator lead was then mobilized and freed of any adhesion to the leaflets. The lead was then positioned in the potential “cleft” between the septal and inferior/posterior leaflets of the tricuspid valve. This cleft was then closed over the lead with 1 or 2 5-0 TiCron sutures (Covidien, New Haven, CT). If this cleft does not exist, the junction between the septal and inferior leaflets is split with a sharp No. 11 blade toward the annulus. The lead is then tucked into this split area and the leaflet edges are reconstituted above with 5-0 TiCron sutures. If the annulus is significantly dilated, a flexible ring is implanted with multiple 2-0 TiCron sutures placed through the annulus, just encroaching onto the edges of the annulus subtended by the septal leaflet. Figure 2 shows the steps of this operative technique. If the annulus is not grossly enlarged, the annulus is bolstered with a pledgeted 3-0 polypropylene suture to get an annuloplasty that measures about 28 to 29 mm. 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2015.08.080
FEATURE ARTICLES
he tricuspid valve is almost always traversed when a permanent pacemaker is implanted through the transvenous route. Despite the knowledge that mild degrees of tricuspid regurgitation can be caused by the ventricular lead going across the right-sided atrioventricular valve [1], often this does not have a clinical consequence. Occasionally, pacing leads have been known to cause severe tricuspid regurgitation [2]. The lifesaving properties of implantable cardioverter defibrillators in patients with poor ventricular function have been effective in reducing the risk of sudden cardiac death [3]. There is widespread use of implantable cardioverter defibrillators in many patients with poor ventricular function, and they seem to confer a survival benefit [4]. Patients with these implanted devices who undergo surgical intervention present a conundrum. Repair of these tricuspid valves can be difficult because the valvular regurgitation is frequently caused by the stiff ventricular cardioverter defibrillator lead impinging on the septal leaflet and not by annular enlargement [5]. We describe a technique that preserves the leads, the tricuspid valve leaflets, and the mechanism with an annuloplasty to deal with this condition. Our experience was from July 2005 to July 2015 at 2 academic centers in Chicago, Illinois. These patients underwent tricuspid valve repair for tricuspid regurgitation in the presence of previously implanted transvenous cardioverter defibrillator leads. All these patients were symptomatic with a New York Heart Association classification of III or IV. The mean patient age was 67 years, ranging from 38 to 80 years. Fifteen (55%) patients underwent redo operations. Seven of these procedures were
(Ann Thorac Surg 2016;101:1599–601) Ó 2016 by The Society of Thoracic Surgeons
1600
HOW TO DO IT RAMAN ET AL COMPLEX TRICUSPID VALVE REPAIR
Fig 1. Operative photograph of defibrillator lead traversing tricuspid valve impinging on and pushing down septal leaflet of tricuspid valve.
Ann Thorac Surg 2016;101:1599–601
In our series, 9 patients had a DeVega-type suture annuloplasty, whereas the other 33 had a flexible ring annuloplasty. This technique requires normal pliable leaflets. If there is fibrosis of any of the leaflets or if there is significant subvalvar fibrosis, this technique may not be applicable. This procedure is best performed when right ventricular function, even if impaired, is recoverable. Large poorly contractile right ventricles might be very poor substrates for any kind of tricuspid intervention. There were no perioperative deaths in our series. Mean tricuspid regurgitation preoperatively was 3.8 and fell to a mean of 1.2 and the mean central venous pressure fell from 34 to 12 mm Hg immediately after the surgery. The mean postoperative stay was 11.5 days (ranging from 5–43 days). At a mean follow up of 22 weeks (range, 4–80 weeks), all patients had only trivial or mild tricuspid regurgitation. There was no instance of moderate or severe tricuspid regurgitation on follow-up.
Comment
FEATURE ARTICLES
Tricuspid valve regurgitation has a known association with right ventricular pacing [6], but over the years improvements in design have reduced this risk. More recently, the cost and survival benefit of pacer cardioverter defibrillators in preventing sudden death [7] has led to increased use of these devices. The problem posed by the increased use of these pacer defibrillators and their impact on tricuspid regurgitation was highlighted in Lin and colleagues’ [8] publication from the Mayo Clinic. The majority of patients in this series had evidence of the stiff lead pushing down on the septal leaflet, keeping it stented in an open position and thereby preventing coaptation with the other 2 leaflets during closure. More recently, a larger group of patients carefully studied from Utrecht, showed evidence of poor prognosis if lead-related tricuspid regurgitation was left alone [9]. Intraoperatively, while dealing with the tricuspid valve, the 2 issues that we can address easily are the lead impingement on the septal leaflet both in the acute and chronic setting and the annular dimensions. The lead is then retained in that position by a fine edge-to-edge suture that closes the cleft over the lead. The annulus is stabilized with an annuloplasty. Our recommendations are to consider this kind of repair in patients with severe tricuspid regurgitation in the presence of transvenous pacing defibrillator leads, preserved leaflets, and reasonable right ventricular function. This may then modify the prognosis favorably in these patients.
References Fig 2. Steps of repair: (1) Mobilized defibrillator lead and leaflets of tricuspid valve, (2) lead repositioned in cleft between septal and inferior/posterior leaflets with suture approximation of leaflets above cleft, and (3) repositioned lead with cleft closure and tricuspid valve annuloplasty.
1. Schnittger I, Appleton CP, Hatle LK, Popp RL. Diastolic mitral and tricuspid regurgitation by Doppler echocardiography in patients with atrioventricular block: new insight into the mechanism of atrioventricular valve closure. J Am Coll Cardiol 1988;11:83–8. 2. Gibson TC, Davidson RC, DeSilvey DL. Presumptive tricuspid valve malfunction induced by a pacemaker lead: a case report
Ann Thorac Surg 2016;101:1599–601
and review of the literature. Pacing Clin Electrophysiol 1980;3: 88–95. 3. Coats AJ. MADIT II, the Multi-center Autonomic Defibrillator Implantation Trial II stopped early for mortality reduction, has ICD therapy earned its evidence-based credentials? Int J Cardiol 2002;82:1–5. 4. Zareba W, Piotrowicz K, McNitt S, Moss AJ, MADIT II Investigators. Implantable cardioverter-defibrillator efficacy in patients with heart failure and left ventricular dysfunction (from the MADIT II population). Am J Cardiol 2005;95:1487–91. 5. Sakai M, Ohkawa S, Ueda K, et al. Tricuspid regurgitation induced by transvenous right ventricular pacing: echocardiographic and pathological observations [Article in Japanese]. J Cardiol 1987;17:311–20.
HOW TO DO IT RAMAN ET AL COMPLEX TRICUSPID VALVE REPAIR
1601
6. Morgan DE, Norman R, West RO, Burggraf G. Echocardiographic assessment of tricuspid regurgitation during ventricular demand pacing. Am J Cardiol 1986;58:1025–9. 7. Sanders GD, Hlatky MA, Owens DK. Cost-effectiveness of implantable cardioverter-defibrillators. N Engl J Med 2005;353:1471–80. 8. Lin G, Nishimura RA, Connolly HM, Dearani JA, Sundt TM 3rd, Hayes DL. Severe symptomatic tricuspid valve regurgitation due to permanent pacemaker or implantable cardioverter-defibrillator leads. J Am Coll Cardiol 2005;45: 1672–5. 9. Hoke U, Auger D, Thijssen J, et al. Significant lead-induced tricuspid regurgitation is associated with poor prognosis at long-term follow-up. Heart 2014;100:960–8.
FEATURE ARTICLES
Complex Tricuspid Valve Repair in Patients With Pacer Defibrillator–Related Tricuspid Regurgitation Jaishankar Raman, MMedBS, PhD, Lissa Sugeng, MD, MPH, David T. M. Lai, MD, FRACS, and Valluvan Jeevanandam, MD Department of Cardiovascular and Thoracic Surgery, Rush University Medical Center, Chicago; Department of Medicine, Yale University Medical Center, New Haven, Connecticut; Department of Surgery, National University of Singapore, Singapore; and Department of Surgery, University of Chicago, Chicago, Illinois
Tricuspid valve regurgitation in patients with heart failure or in those undergoing complex cardiac operations is associated with increased morbidity and mortality. We report our results with a technique of repairing the tricuspid valves while retaining the pacer defibrillator lead. Patients had tricuspid valve repairs that included repositioning of the pacer defibrillator
lead, approximation of septal and inferior/posterior leaflets in a modified cleft repair, and implantation of a tricuspid annuloplasty ring. This procedure was performed in more than 42 patients with good success.
T
through a right minithoracotomy, and 5 of these patients had a third or fourth redo procedure. Associated procedures included mitral valve reconstruction in 21 patients, ventricular assist device implantation in 5 patients, coronary artery bypass grafting in 11 patients, left ventricular reconstruction in 8 patients, and aortic valve replacement in 3 patients. Two patients had stand-alone procedures through a right minithoracotomy.
Accepted for publication Aug 26, 2015. Address correspondence to Dr Raman, Department of Cardiovascular and Thoracic Surgery, Rush University Medical Center, 1653 W Congress Pkwy, Chicago, IL 60612; email: [email protected].
Ó 2016 by The Society of Thoracic Surgeons Published by Elsevier
Technique The right atrium was opened with a longitudinal incision and the tricuspid valve was assessed. Stay sutures were placed above the valve annulus in the atrium to display the valve. The mechanism of tricuspid regurgitation was assessed with the heart beating on cardiopulmonary bypass. Figure 1 shows an intraoperative photograph demonstrating the stiff defibrillator lead pushing on the septal leaflet as it traverses the tricuspid annulus. The pacer defibrillator lead was then mobilized and freed of any adhesion to the leaflets. The lead was then positioned in the potential “cleft” between the septal and inferior/posterior leaflets of the tricuspid valve. This cleft was then closed over the lead with 1 or 2 5-0 TiCron sutures (Covidien, New Haven, CT). If this cleft does not exist, the junction between the septal and inferior leaflets is split with a sharp No. 11 blade toward the annulus. The lead is then tucked into this split area and the leaflet edges are reconstituted above with 5-0 TiCron sutures. If the annulus is significantly dilated, a flexible ring is implanted with multiple 2-0 TiCron sutures placed through the annulus, just encroaching onto the edges of the annulus subtended by the septal leaflet. Figure 2 shows the steps of this operative technique. If the annulus is not grossly enlarged, the annulus is bolstered with a pledgeted 3-0 polypropylene suture to get an annuloplasty that measures about 28 to 29 mm. 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2015.08.080
FEATURE ARTICLES
he tricuspid valve is almost always traversed when a permanent pacemaker is implanted through the transvenous route. Despite the knowledge that mild degrees of tricuspid regurgitation can be caused by the ventricular lead going across the right-sided atrioventricular valve [1], often this does not have a clinical consequence. Occasionally, pacing leads have been known to cause severe tricuspid regurgitation [2]. The lifesaving properties of implantable cardioverter defibrillators in patients with poor ventricular function have been effective in reducing the risk of sudden cardiac death [3]. There is widespread use of implantable cardioverter defibrillators in many patients with poor ventricular function, and they seem to confer a survival benefit [4]. Patients with these implanted devices who undergo surgical intervention present a conundrum. Repair of these tricuspid valves can be difficult because the valvular regurgitation is frequently caused by the stiff ventricular cardioverter defibrillator lead impinging on the septal leaflet and not by annular enlargement [5]. We describe a technique that preserves the leads, the tricuspid valve leaflets, and the mechanism with an annuloplasty to deal with this condition. Our experience was from July 2005 to July 2015 at 2 academic centers in Chicago, Illinois. These patients underwent tricuspid valve repair for tricuspid regurgitation in the presence of previously implanted transvenous cardioverter defibrillator leads. All these patients were symptomatic with a New York Heart Association classification of III or IV. The mean patient age was 67 years, ranging from 38 to 80 years. Fifteen (55%) patients underwent redo operations. Seven of these procedures were
(Ann Thorac Surg 2016;101:1599–601) Ó 2016 by The Society of Thoracic Surgeons
1600
HOW TO DO IT RAMAN ET AL COMPLEX TRICUSPID VALVE REPAIR
Fig 1. Operative photograph of defibrillator lead traversing tricuspid valve impinging on and pushing down septal leaflet of tricuspid valve.
Ann Thorac Surg 2016;101:1599–601
In our series, 9 patients had a DeVega-type suture annuloplasty, whereas the other 33 had a flexible ring annuloplasty. This technique requires normal pliable leaflets. If there is fibrosis of any of the leaflets or if there is significant subvalvar fibrosis, this technique may not be applicable. This procedure is best performed when right ventricular function, even if impaired, is recoverable. Large poorly contractile right ventricles might be very poor substrates for any kind of tricuspid intervention. There were no perioperative deaths in our series. Mean tricuspid regurgitation preoperatively was 3.8 and fell to a mean of 1.2 and the mean central venous pressure fell from 34 to 12 mm Hg immediately after the surgery. The mean postoperative stay was 11.5 days (ranging from 5–43 days). At a mean follow up of 22 weeks (range, 4–80 weeks), all patients had only trivial or mild tricuspid regurgitation. There was no instance of moderate or severe tricuspid regurgitation on follow-up.
Comment
FEATURE ARTICLES
Tricuspid valve regurgitation has a known association with right ventricular pacing [6], but over the years improvements in design have reduced this risk. More recently, the cost and survival benefit of pacer cardioverter defibrillators in preventing sudden death [7] has led to increased use of these devices. The problem posed by the increased use of these pacer defibrillators and their impact on tricuspid regurgitation was highlighted in Lin and colleagues’ [8] publication from the Mayo Clinic. The majority of patients in this series had evidence of the stiff lead pushing down on the septal leaflet, keeping it stented in an open position and thereby preventing coaptation with the other 2 leaflets during closure. More recently, a larger group of patients carefully studied from Utrecht, showed evidence of poor prognosis if lead-related tricuspid regurgitation was left alone [9]. Intraoperatively, while dealing with the tricuspid valve, the 2 issues that we can address easily are the lead impingement on the septal leaflet both in the acute and chronic setting and the annular dimensions. The lead is then retained in that position by a fine edge-to-edge suture that closes the cleft over the lead. The annulus is stabilized with an annuloplasty. Our recommendations are to consider this kind of repair in patients with severe tricuspid regurgitation in the presence of transvenous pacing defibrillator leads, preserved leaflets, and reasonable right ventricular function. This may then modify the prognosis favorably in these patients.
References Fig 2. Steps of repair: (1) Mobilized defibrillator lead and leaflets of tricuspid valve, (2) lead repositioned in cleft between septal and inferior/posterior leaflets with suture approximation of leaflets above cleft, and (3) repositioned lead with cleft closure and tricuspid valve annuloplasty.
1. Schnittger I, Appleton CP, Hatle LK, Popp RL. Diastolic mitral and tricuspid regurgitation by Doppler echocardiography in patients with atrioventricular block: new insight into the mechanism of atrioventricular valve closure. J Am Coll Cardiol 1988;11:83–8. 2. Gibson TC, Davidson RC, DeSilvey DL. Presumptive tricuspid valve malfunction induced by a pacemaker lead: a case report
Ann Thorac Surg 2016;101:1599–601
and review of the literature. Pacing Clin Electrophysiol 1980;3: 88–95. 3. Coats AJ. MADIT II, the Multi-center Autonomic Defibrillator Implantation Trial II stopped early for mortality reduction, has ICD therapy earned its evidence-based credentials? Int J Cardiol 2002;82:1–5. 4. Zareba W, Piotrowicz K, McNitt S, Moss AJ, MADIT II Investigators. Implantable cardioverter-defibrillator efficacy in patients with heart failure and left ventricular dysfunction (from the MADIT II population). Am J Cardiol 2005;95:1487–91. 5. Sakai M, Ohkawa S, Ueda K, et al. Tricuspid regurgitation induced by transvenous right ventricular pacing: echocardiographic and pathological observations [Article in Japanese]. J Cardiol 1987;17:311–20.
HOW TO DO IT RAMAN ET AL COMPLEX TRICUSPID VALVE REPAIR
1601
6. Morgan DE, Norman R, West RO, Burggraf G. Echocardiographic assessment of tricuspid regurgitation during ventricular demand pacing. Am J Cardiol 1986;58:1025–9. 7. Sanders GD, Hlatky MA, Owens DK. Cost-effectiveness of implantable cardioverter-defibrillators. N Engl J Med 2005;353:1471–80. 8. Lin G, Nishimura RA, Connolly HM, Dearani JA, Sundt TM 3rd, Hayes DL. Severe symptomatic tricuspid valve regurgitation due to permanent pacemaker or implantable cardioverter-defibrillator leads. J Am Coll Cardiol 2005;45: 1672–5. 9. Hoke U, Auger D, Thijssen J, et al. Significant lead-induced tricuspid regurgitation is associated with poor prognosis at long-term follow-up. Heart 2014;100:960–8.
FEATURE ARTICLES