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Traumatic tricuspid valve injury: Leaflet resuspension repair
Ann Thorac Surg 1996;61:721-2
CASE REPORT BOLTON TRICUSPID VALVE REPAIR
721
6. Stal JM, Hanley PJ, Darling GE. Gastrobrochial fistula: an unusual complication of esophagectomy. Ann Thorac Surg 1994;58:886 -7. 7. Poje CP, Keane W, Atkins JP, Pribitkin E. Tracheo-gastric fistula following gastric pull-up. Ear Nose Throat J 1991;70: 848 -50. 8. Kron IL, Johnson AM, Morgan RF. Gastrotracheal fistula: a late complication after transhiatal esophagectomy. Ann Thorac Surg 1989;47:767-8.
Traumatic Tricuspid Valve Injury: Leaflet Resuspension Repair Joe W. R. Bolton, MD Department of Cardiothoracic Surgery, Wilford Hall USAF Medical Center, Lackland Air Force Base, Texas Blunt traumatic rupture of the tricuspid valve is exceedingly u n c o m m o n , and injury of the tricuspid valve due to penetrating trauma appears to be even more rare. Presented here is a case of tricuspid valve injury due to penetrating cardiac trauma repaired by leaflet resuspension 17 years later.
(Ann Thorac Surg 1996;61:721-2) he patient is a 37-year-old man who was a d m i t t e d for evaluation of severe shortness of b r e a t h and dysp n e a on exertion. His past history was significant for a stab w o u n d to the right ventricle at 20 years of age, which was r e p a i r e d via an u n c o m p l i c a t e d left thoracotomy and oversewing of the stab wound. There was no evaluation of intracardiac structures. Over the next 17 years he r e q u i r e d n u m e r o u s hospital admissions for progressive shortness of b r e a t h a n d was unable to p e r f o r m even the lightest workload. On admission, the patient was m o d e r a t e l y short of breath and mildly dyspneic. Physical examination was significant for a m u r m u r of tricuspid insufficiency. He h a d a b o u n d i n g jugular venous pulse as well as some hepatic e n l a r g e m e n t . The e l e c t r o c a r d i o g r a m s h o w e d atrial fibrillation with a controlled ventricular response of 70 to 80 beats/rain. Chest r o e n t g e n o g r a m indicated an enlarged right atrium and right ventricle as well as clear lung fields (Fig 1). An echocardiogram confirmed a massively dilated right atrium a n d right ventricle a n d d e m onstrated unrestricted tricuspid regurgitation with only one tricuspid leaflet identifiable. Cardiac catheterization revealed ventricularization of the right atrial pressures (Fig 2). He was taken to the operating r o o m for tricuspid
T
Fig 1. Preoperative chest roentgenogram.
valve repair or replacement. During cannulation, the tricuspid regurgitant jet was p a l p a t e d through the right atrial a p p e n d a g e and felt to be totally unrestricted. After institution of c a r d i o p u l m o n a r y bypass with bicaval cannulation and aortic cross-clamping the right atrium was opened. Inspection of the tricuspid valve revealed the septal a n d posterior leaflets to be intact. The anterior leaflet was almost completely d e t a c h e d from the annulus, being connected only at the commissure of the septal leaflet. The subvalvular m e c h a n i s m was intact. The annulus was t r e m e n d o u s l y dilated. The valve was r e p a i r e d by leaflet r e s u s p e n s i o n along the annulus with a continuous 4-0 Prolene suture (Ethicon, Somerville, NJ). Because the greatly dilated annulus p r e c l u d e d a d e q u a t e leaflet approximation, the valve was bicuspidized by closing the cleft b e t w e e n the anterior and posterior leaflets with i n t e r r u p t e d figure-of-8 5-0 Prolene suture and a 36-mm C a r p e n t i e r - E d w a r d s tricuspid valve annuloplasty ring was placed. Testing with saline solution revealed a mild central jet without prolapse. The patient was easily w e a n e d from c a r d i o p u l m o n a r y bypass. After decannulation, p a l p a t i o n through the atrial a p p e n d a g e revealed a small tricuspid jet, which was greatly r e d u c e d from the torrential flow noted on preoperative palpation. A right atrial pressure m e a s u r i n g line was placed through the tricuspid valve into the right ventricle a n d on pull-back revealed the expected right atrial pressures, which m i m -
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Accepted for publication Aug 10, 1995. Address reprint requests to Dr Bolton, Wilford Hall Medical Center/ PSST, 2200 Bergquist Dr, Suite 1, Lackland Air Force Base, TX 782365300.
© 1996 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
on
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Fig 2. Preoperative right atrial (RA) pressure tracing.
0003-4975/96/$15.00 SSD! 0003-4975(95)00860-8
722
CASEREPORT BOLTON TRICUSPID VALVEREPAIR
aD-
3e
Fig 3. Postrepair pressure tracing pull-back. (CVP = central venous pressure; EKG - electrocardiogram; R A = right atrium; RV = right ventricle.)
icked the central venous pressure. The ventricularized pressure was absent (Fig 3). He was discharged from the hospital in sinus r h y t h m on postoperative day 7. Six weeks after the operation he r e t u r n e d to work for the first time since his original injury. At 3-month follow-up, he r e m a i n e d in sinus r h y t h m and had a decrease in the size of his cardiac s h a d o w by chest r o e n t g e n o g r a m (Fig 4). Comment Isolated traumatic injury to the tricuspid valve a n d its s u p p o r t i n g structures is extremely rare, with only about 100 cases having b e e n r e p o r t e d in the literature [1-3]. Even though 94% of cardiac t r a u m a involves p e n e t r a t i n g injuries, the vast majority of r e p o r t e d cases of traumatic tricuspid insufficiency has been due to b l u n t t r a u m a [3]. Of those injuries involving cardiac valves, aortic valve r u p t u r e is most frequent, followed by d a m a g e to the mitral valve. Injury to the tricuspid valve is the most rare of valvular injuries [4]. The original t r e a t m e n t of traumatic tricuspid insufficiency was valve repair because the results of valve r e p l a c e m e n t in this position were poor. Valve replace-
Ann Thorac Surg 1996;61:721-2
m e n t with a porcine bioprosthesis did not offer an acceptable longevity and the use of a mechanical valve resulted in an unacceptable incidence of t h r o m b o e m b o lism a n d complications associated with long-term anticoagulation. Unfortunately, an initial poor experience resulting from residual a n d recurrent valvular insufficiency resulted in long-term nonoperative m a n a g e m e n t because the tricuspid regurgitation could be well tolerated for years [2, 4, 5]. However, because of worsening s y m p t o m s nearly all patients eventually came to operation. Valve r e p l a c e m e n t then b e c a m e the operation of choice due to the prior poor experience with repair. Techniques d e v e l o p e d with mitral valve repair have i m p r o v e d the ability to attain acceptable results from tricuspid valve repair after blunt or penetrating trauma. Currently, it is r e c o m m e n d e d that an attempt should be m a d e to repair the valve even if valve r e p l a c e m e n t at a later date m a y be inevitable [2-7]. It is i m p o r t a n t to be aware of a wide variety of techniques because the nature of the injury dictates the m e t h o d of repair. Most injuries involve the subvalvular structures, and because of the usual delay in diagnosis s p a n n i n g weeks to years, a dilated annulus is nearly always present. In these cases, it is necessary to address not only the injury to the papillary muscles or chordae, b u t also the a n n u l a r dilatation. Occasionally, as in this case, the valve leaflet itself dem a n d s attention. W i t h the techniques available today, once diagnosed, the tricuspid insufficiency should be a p p r o a c h e d surgically with a plan t o w a r d repair. The specific repair is g u i d e d by the circumstances and requires ingenuity a n d innovation. Although valve r e p l a c e m e n t is sometimes necessary,, the r e p o r t e d results after operation, either acute or delayed, have b e e n gratifying. The majority of patients who have u n d e r g o n e reparative operations, as in this case, have been freed from their disability and r e t u r n e d to a productive lifestyle.
References
Fig 4. Chest roentgenogram 3 months postoperatively.
1. Linka A, Ritter M, Turina M, et al. Acute tricuspid papillary muscle rupture following blunt chest trauma. Am Heart J 1992;124:799 -802. 2. Kleikamp G, Schnepper U, Kortke H, et al. Tricuspid valve regurgitation following blunt thoracic trauma. Chest 1992;102: 1294- 6. 3. Dontigny L, Baillot R, Panneton J, et al. Surgical repair of traumatic tricuspid insufficiency: report of three cases. J Trauma 1992;33:266-9. 4. Liedtke AJ, Demuth WE Jr. Nonpenetrating cardiac injuries: a collective review. Am Heart J 1973;86:678-97. 5. Katz NM, Pallas RS. Traumatic rupture of the tricuspid valve: repair by chordal replacements and annuloplasty. J Thorac Cardiovasc Surg 1986;91:310-4. 6. Noera G, Sanguinetti M, Pensa P, et al. Tricuspid valve incompetence caused by nonpenetrating thoracic trauma. Ann Thorac Surg 1991;51:320-32. 7. Naja I, Barriuso C, Ninot S, et al. Traumatic rupture of the tricuspid valve. Its conservative surgical treatment. Rev Esp Cardiol 1992;45:64-6.
CASE REPORT BOLTON TRICUSPID VALVE REPAIR
721
6. Stal JM, Hanley PJ, Darling GE. Gastrobrochial fistula: an unusual complication of esophagectomy. Ann Thorac Surg 1994;58:886 -7. 7. Poje CP, Keane W, Atkins JP, Pribitkin E. Tracheo-gastric fistula following gastric pull-up. Ear Nose Throat J 1991;70: 848 -50. 8. Kron IL, Johnson AM, Morgan RF. Gastrotracheal fistula: a late complication after transhiatal esophagectomy. Ann Thorac Surg 1989;47:767-8.
Traumatic Tricuspid Valve Injury: Leaflet Resuspension Repair Joe W. R. Bolton, MD Department of Cardiothoracic Surgery, Wilford Hall USAF Medical Center, Lackland Air Force Base, Texas Blunt traumatic rupture of the tricuspid valve is exceedingly u n c o m m o n , and injury of the tricuspid valve due to penetrating trauma appears to be even more rare. Presented here is a case of tricuspid valve injury due to penetrating cardiac trauma repaired by leaflet resuspension 17 years later.
(Ann Thorac Surg 1996;61:721-2) he patient is a 37-year-old man who was a d m i t t e d for evaluation of severe shortness of b r e a t h and dysp n e a on exertion. His past history was significant for a stab w o u n d to the right ventricle at 20 years of age, which was r e p a i r e d via an u n c o m p l i c a t e d left thoracotomy and oversewing of the stab wound. There was no evaluation of intracardiac structures. Over the next 17 years he r e q u i r e d n u m e r o u s hospital admissions for progressive shortness of b r e a t h a n d was unable to p e r f o r m even the lightest workload. On admission, the patient was m o d e r a t e l y short of breath and mildly dyspneic. Physical examination was significant for a m u r m u r of tricuspid insufficiency. He h a d a b o u n d i n g jugular venous pulse as well as some hepatic e n l a r g e m e n t . The e l e c t r o c a r d i o g r a m s h o w e d atrial fibrillation with a controlled ventricular response of 70 to 80 beats/rain. Chest r o e n t g e n o g r a m indicated an enlarged right atrium and right ventricle as well as clear lung fields (Fig 1). An echocardiogram confirmed a massively dilated right atrium a n d right ventricle a n d d e m onstrated unrestricted tricuspid regurgitation with only one tricuspid leaflet identifiable. Cardiac catheterization revealed ventricularization of the right atrial pressures (Fig 2). He was taken to the operating r o o m for tricuspid
T
Fig 1. Preoperative chest roentgenogram.
valve repair or replacement. During cannulation, the tricuspid regurgitant jet was p a l p a t e d through the right atrial a p p e n d a g e and felt to be totally unrestricted. After institution of c a r d i o p u l m o n a r y bypass with bicaval cannulation and aortic cross-clamping the right atrium was opened. Inspection of the tricuspid valve revealed the septal a n d posterior leaflets to be intact. The anterior leaflet was almost completely d e t a c h e d from the annulus, being connected only at the commissure of the septal leaflet. The subvalvular m e c h a n i s m was intact. The annulus was t r e m e n d o u s l y dilated. The valve was r e p a i r e d by leaflet r e s u s p e n s i o n along the annulus with a continuous 4-0 Prolene suture (Ethicon, Somerville, NJ). Because the greatly dilated annulus p r e c l u d e d a d e q u a t e leaflet approximation, the valve was bicuspidized by closing the cleft b e t w e e n the anterior and posterior leaflets with i n t e r r u p t e d figure-of-8 5-0 Prolene suture and a 36-mm C a r p e n t i e r - E d w a r d s tricuspid valve annuloplasty ring was placed. Testing with saline solution revealed a mild central jet without prolapse. The patient was easily w e a n e d from c a r d i o p u l m o n a r y bypass. After decannulation, p a l p a t i o n through the atrial a p p e n d a g e revealed a small tricuspid jet, which was greatly r e d u c e d from the torrential flow noted on preoperative palpation. A right atrial pressure m e a s u r i n g line was placed through the tricuspid valve into the right ventricle a n d on pull-back revealed the expected right atrial pressures, which m i m -
~r
1~
0n,w993 1~ st
II
:, 4 3 0 ~
05 p~rlEur ec~ ~a~n
t
~ELAY~ 0x
i
25
n.,s ,r-it
l e ~ 92 s
I n
Accepted for publication Aug 10, 1995. Address reprint requests to Dr Bolton, Wilford Hall Medical Center/ PSST, 2200 Bergquist Dr, Suite 1, Lackland Air Force Base, TX 782365300.
© 1996 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
on
i~.A
pre~ure p w
n
Fig 2. Preoperative right atrial (RA) pressure tracing.
0003-4975/96/$15.00 SSD! 0003-4975(95)00860-8
722
CASEREPORT BOLTON TRICUSPID VALVEREPAIR
aD-
3e
Fig 3. Postrepair pressure tracing pull-back. (CVP = central venous pressure; EKG - electrocardiogram; R A = right atrium; RV = right ventricle.)
icked the central venous pressure. The ventricularized pressure was absent (Fig 3). He was discharged from the hospital in sinus r h y t h m on postoperative day 7. Six weeks after the operation he r e t u r n e d to work for the first time since his original injury. At 3-month follow-up, he r e m a i n e d in sinus r h y t h m and had a decrease in the size of his cardiac s h a d o w by chest r o e n t g e n o g r a m (Fig 4). Comment Isolated traumatic injury to the tricuspid valve a n d its s u p p o r t i n g structures is extremely rare, with only about 100 cases having b e e n r e p o r t e d in the literature [1-3]. Even though 94% of cardiac t r a u m a involves p e n e t r a t i n g injuries, the vast majority of r e p o r t e d cases of traumatic tricuspid insufficiency has been due to b l u n t t r a u m a [3]. Of those injuries involving cardiac valves, aortic valve r u p t u r e is most frequent, followed by d a m a g e to the mitral valve. Injury to the tricuspid valve is the most rare of valvular injuries [4]. The original t r e a t m e n t of traumatic tricuspid insufficiency was valve repair because the results of valve r e p l a c e m e n t in this position were poor. Valve replace-
Ann Thorac Surg 1996;61:721-2
m e n t with a porcine bioprosthesis did not offer an acceptable longevity and the use of a mechanical valve resulted in an unacceptable incidence of t h r o m b o e m b o lism a n d complications associated with long-term anticoagulation. Unfortunately, an initial poor experience resulting from residual a n d recurrent valvular insufficiency resulted in long-term nonoperative m a n a g e m e n t because the tricuspid regurgitation could be well tolerated for years [2, 4, 5]. However, because of worsening s y m p t o m s nearly all patients eventually came to operation. Valve r e p l a c e m e n t then b e c a m e the operation of choice due to the prior poor experience with repair. Techniques d e v e l o p e d with mitral valve repair have i m p r o v e d the ability to attain acceptable results from tricuspid valve repair after blunt or penetrating trauma. Currently, it is r e c o m m e n d e d that an attempt should be m a d e to repair the valve even if valve r e p l a c e m e n t at a later date m a y be inevitable [2-7]. It is i m p o r t a n t to be aware of a wide variety of techniques because the nature of the injury dictates the m e t h o d of repair. Most injuries involve the subvalvular structures, and because of the usual delay in diagnosis s p a n n i n g weeks to years, a dilated annulus is nearly always present. In these cases, it is necessary to address not only the injury to the papillary muscles or chordae, b u t also the a n n u l a r dilatation. Occasionally, as in this case, the valve leaflet itself dem a n d s attention. W i t h the techniques available today, once diagnosed, the tricuspid insufficiency should be a p p r o a c h e d surgically with a plan t o w a r d repair. The specific repair is g u i d e d by the circumstances and requires ingenuity a n d innovation. Although valve r e p l a c e m e n t is sometimes necessary,, the r e p o r t e d results after operation, either acute or delayed, have b e e n gratifying. The majority of patients who have u n d e r g o n e reparative operations, as in this case, have been freed from their disability and r e t u r n e d to a productive lifestyle.
References
Fig 4. Chest roentgenogram 3 months postoperatively.
1. Linka A, Ritter M, Turina M, et al. Acute tricuspid papillary muscle rupture following blunt chest trauma. Am Heart J 1992;124:799 -802. 2. Kleikamp G, Schnepper U, Kortke H, et al. Tricuspid valve regurgitation following blunt thoracic trauma. Chest 1992;102: 1294- 6. 3. Dontigny L, Baillot R, Panneton J, et al. Surgical repair of traumatic tricuspid insufficiency: report of three cases. J Trauma 1992;33:266-9. 4. Liedtke AJ, Demuth WE Jr. Nonpenetrating cardiac injuries: a collective review. Am Heart J 1973;86:678-97. 5. Katz NM, Pallas RS. Traumatic rupture of the tricuspid valve: repair by chordal replacements and annuloplasty. J Thorac Cardiovasc Surg 1986;91:310-4. 6. Noera G, Sanguinetti M, Pensa P, et al. Tricuspid valve incompetence caused by nonpenetrating thoracic trauma. Ann Thorac Surg 1991;51:320-32. 7. Naja I, Barriuso C, Ninot S, et al. Traumatic rupture of the tricuspid valve. Its conservative surgical treatment. Rev Esp Cardiol 1992;45:64-6.