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Tricuspid Valve Replacement
Tricuspid Valve Replacement John R. Dory, MD, and Donald B. Dory, MD Perations on the tricuspid valve are usually performed in conjunction with treatment of some other valvular heart disease. Most commonly, the morphology of the tricuspid valve is dilation of the anulus secondary to pulmonary hypertension and right ventricular dilation associated with mitral or combined mitral and aortic valve disease. Anular dilation results in tricuspid valve regurgitation. The tricuspid valve leaflet tissues are normal or near normal so that repair of the tricuspid valve by anuloplasty techniques is nearly always possible and tricuspid valve replacement is sddom necessary. There are some pathologic processes that directly involve the tricuspid valve leaflet tissues. Valve repair may not be possible, and replacement is required. Tricuspid valve endocarditis, acute or subacute, may result in destruction of enough leaflet tissue to require valve replacement. Endocarditis may be associated with pacemaker electrodes passed through the venous system adherent to the tricuspid valve
O
leaflet
and lodged in the right ventricle. Rheumatic heart disease may affect the tricuspid valve in conjtmction with other cardiac valves. 1 The morphology is valve leaflet thickening and retraction with commissural fusion resulting in tricuspid valve stenosis and/or regurgitation. Carcinoid tumors producing serotonin (t-hydroxytryptamine) may destroy the tricuspid valve (and pulmonary valve) by cicatricial changes in leaflet tissues causing tricuspid stenosis and regurgitation.2 Similar changes are seen in patients using phentermine-fenfloramine for appetite control. Tricuspid valve regurgitation, commonly associated with cardiac transplantation,3 may become severe when associated with ruptured chordae tendinae from multiple right heart biopsies. There are some tricuspid valves affected by Ebstein's anomaly40z that are so severely deformed that repair is either ineffective or impossible so that valve replacement is necessary. Methods of tricuspid valve replacement are detailed in this paper.
Coronary sinus
| Tricuspid valve replacement with mechanical or stented bioprosthetic valve. Tricuspid valve operations are performed via a standard midline sternotomy (complete or lower one half) or through an anterior thoracotomy on the right side. Cardiopulmonary bypass is established using two cannulae for venous uptake (inset figure) with oxygenated blood returned to a cannula placed in the ascending aorta. Tourniquets are secured around the vena cavae and cannulae to isolate the right atrium. Some operations lend well to continuous coronary perfusion, but most procedures are performed with the aorta occluded and the heart arrested by cold cardioplegic solution administered through a catheter in the coronary sinus. The tricuspid valve is excised beginning with the anterior leaflet, continuing around the posterior leaflet, and finally completing the excision over the septal leaflet. Nearly all or at least a considerable rim of the septal leaflet of the tricuspid valve should be preserved for attachment of the valve prosthesis. The appropriate size valve prosthesis is selected based on measurements using valve anulus calibrators. Operative Techniques in Thoracic and Cardiovascular Surgery, Vol 8, No 4 (November), 2003: pp 193-200
193
Septal leaflet
Atri0ventricular node
uoronary sinus
2 Pledger reinforced mattress sutures are used to buttress and strengthen the tissue repair of the septal leaflet of the tricuspid valve. The stitches are placed through only leaflet tissue at the apex of the triangle of Koch to preserve the integrity and function of" the electrical conduction system. The rest of septal portion of the anulus is repaired by pledger-reinforced sutures passed around the anulus and leaflet remnant. The sutures are passed through the sewing ring of the prosthesis as the stitches are placed in the septal leaflet.
Tricuspid valve anulus
3 The prosthesis is attached to the rest of the anulus by continuous stitches using 2/0 polypropylene suture material. The continuous suture is started as a pledget-reinforced mattress stitch placed around the anulus anteriorly and brought through the sewing ring of the prosthesis. The prosthesis is placed in the right ventricle and the suture tightened to approximate the sewing ring of the prosthesis to the valve annulus. Stitches are placed from the anulus to the sewing ring of the prosthesis, worldng in a clockwise fashion. Tension is n|aintained on the suture to approximatel the tissues firmly to the sewing ring of the prosthesis. Tension is released with each needle pass to facilitate exposure of the junction of ventricular myocardium and the anulus.
195
TRICUSPID VALVE REPLACEMENT
Tricuspid valve anulus
-~i
~'
~=s 7i7 i:i=
W ~S
iI)IIIIII!IIIIIIIIIII(
R 2;" i7
J
4 The stitches are continued to the junction of the anulus of the free wall with the septum. The remainder of the repair is done using the needle at the opposite end of the suture working in a counterclockwise fashion. The needle is passed from the tricuspid anulus to the sewing ring of the prosthesis, continuing to the commissure between septal and anterior leaflets.
/~"/
iii ,:,i: ~ ~i? I ii~ ii~ii:i i
Atriow node
Completed repair 5 The valve replacement is completed by tying sutures securely. An alternate technique involves using all interrupted pledgeted mattress stitches when the tricuspid leaflet tissue and annulus is delicate and not as likely to hold secure with continuous suture technique.
Mitral valv~ homograft
6 Tricuspid valve replacentent with mitral valve homograft. The tricuspid valve is excised and the diameter of the anulus is measured as described above. A mitral valve homograft of the salne anular diameter is chosen. The homograft is cryopreserved and must be thawed, a process that takes approximately 20 minutes. The homograft is trimmed after thawing. The myocardium of the atrium and the ventricle is cut away from the anulus of the homograft, leaving just enough tissue to allow needle penetration without entering leaflet tissue The papillary muscles are shortened, leaving l0 mm of muscle below the chordal attachments.
Tricuspid valve anulus
Atr~ node
Anterior papillary muscle
. . . . . . . .
]
sinus
7 Horizontal mattress stitches (2/0 braided polyester) for auuloplasty are placed through the annlus of the tricuspid valve except for the area occupied by the septal leaflet. These stitches are placed using both needles of a double needle suture passed from the right ventricle to the right atrium through the tricuspid valve anulus. The sutures are placed as the initial step of the operation, as it is easier than after the homograft is in place, exposure is enhanced, and this cml be performed during the homograft thawing process. The anterior papillary muscle of the tricuspid valve is the only one suitable for attachment of the homograft papillary muscle. This papillary muscle supports all of the anterior and part of the posterior leaflets of the tricuspid valve, is usually of good size, and is continuous with the moderator band, which can provide additional support.
Septal leaflet M tri
8 The mitral homograft is oriented with its anterior leaflet to the ventricular septum (septal leaflet area of the tricuspid valve). Orientation is maintained by placing a stitch of 4/0 polypropylene through the fibrous trigones at each end of the homograft anterior leaflet and passing the stitches through recipient tricuspid valve anulus or leaflet remnant at each end of the septal leaflet.
198
DOTY AND DOTY
The anterior papillary muscle of the mitral homograft is positioned side-by-side to the anterior papillary muscle of the recipient tricuspid valve using a horizontal mattress stitch (inset figure). Firm attachment of the donor papillary muscle to the patient papillary muscle is accomplished using 8 to 10 simple stitches of fine monofilament suture (5/0 CardionylTM). A channel is made through the anterior wall of the right ventricle at an appropriate position to accommodate the posterior papillary muscle of the homograft. The papillary muscle is pulled through the channel. It is secured to the epicardial surface of the right ventricle with multiple stitches of 5/0 Cardionyl TM suture. The homograft papillary muscle is also secured to the endocardial surface with multiple sutures.
kl I L ~ ! I U I
~.apillary muscle
~L
Tricuspid valve anulus jJ
.:S
Mitral valve homograft
~I ~ "
][ O The anulus of the homograft is attached to the anulns of the recipient by continuous stitches of 4/0 polypropylene sutures using the stitches previously placed in the fibrous trigones of the homograft. The stitches are placed around the anulus of the patient tricuspid valve and through the atrial remnant and anulus of the homograft.
At~ fig
Completed repair ....... .... ][ ][ An anuloplasty band (Cosgrove Anuloplasty Band TM, Edwards LifeSciences, Anaheim, CA) or pericardial strip is used to support the tricuspid anulus in the portions occupied by the anterior and posterior leaflets. The septal portion is not supported. The anuloplasty band is attached to the tricuspid valve anutus by the previously placed mattress sutures. The anuloplasty band is tied securely to the tricuspid anulus to complete the valve replacement.
|~ 2
Photograph of tricuspid valve replacement with mitral valve homograft supported by Cosgrove Anuloplasty Band TM.
200
DOTY AND DOTY
COMMENTS Replacement of the tricuspid valve is not often required but there are some conditions in which the valve leaflet tissue is deficient or even destroyed to a degree that valve repair is not possible. Operations on the tricuspid valve are usually done concomitantly with operations on other c a r d i a c valves. Isolated tricuspid valve replacement is a high risk procedure with 30-day hospital mortality in the range of 10% to 24%.6-a Complete heart block requiring pacemaker insertion as a complication of tricuspid valve replacement occurred in 28% of 32 patients reported by Do and associates. 9 Choice of replacement device is not conclusive. Significant advantage has not been demonstrated comparing mechanical prostheses to stent-mounted bioprostheses.7,8,1~ Tricuspid valve replacement with mitral valve homograft may offer some advantages in patients with tricuspid valve endocarditis, ~2-~4 especially those infected with drugresistant bacteria or fungus.
REFERENCES 1. Roguin A, Rinkevich D, Marldewica W, et al: Long-term follow-up of patients with severe rheumatic tricuspid stenosis. Am Heart J 136:103108, 1998 2. Connolly HM, Schaff HV, Mullany CJ, et al: Carcinoid heart disease: Impact of pulmonary valve replacement in right ventricular function and remodeling. Circulation 106:I51 I56, 2002, (suppl) 3. Chan MC, Giannetti N, Kato T, et al: Severe tricuspid regurgitation after heart transplantation. J Heart Lung Transplant 20:709-717, 2001
4. Kiziltan HT, Theodoro DA, Warnes CA, et al: Late results of biopros thetic tricuspid valve replacement in EbsteiJa'S anomaly. Ann Thorac Surg 66:1539-1545, 1998 5. Renfu Z, Zengwei W, Hongyu Z, et al: Experience in corrective surgery for Ebstein's anomaly in 139 patients. J Heart Valve Dis 10:396-398, 2001 6. Dalrymple-Hay MJ, Leung Y, Ohri SK, et al: Tricuspid valve replacement: bioprostheses are preferable. J Heart Valve Dis 8:644648, 1999 7. Ratnatunga CP, Edwards MB, Dore CJ, et al: Tricuspid valve replacement: UK Heart Valve Registry mid term results comparing mechanical and biological prostheses. Ann Thorac Surg 66:19401947, 1998 8. Kaplan M, Kut MS, Demirtas MM, et al: Prosthetic replacement of tricuspid valve: bioprosthetie or mechanical. Ann Thorae Surg 73:467473, 2002 9. Do QB, Pellerin M, Carrier M, et al: Clinical outcome after isolated tricuspid valve replacement: 20-year experience. Can J Cardiol 16:489493, 2000 10. Rizzoli G, De Perini L, Bottio T, et al: Prosthetic replacement of the tricuspid valve: biological or mechanical? Ann Thorae Surg 66:$62-$67, 1998, (suppl) 11. Ohata T, I~igawa I, Tohda E, et al: Comparison of durability of bioprostheses in tricuspid and mitral positions. Ann Thorae Surg 71: $240-$243,2001, (suppl) 12. Couetil JP, Argyriadis PG, Shafy A, et al: Partial replacement of the tricuspid valve by mitral homografts in acute endoearditis. Ann Thorae Surg 73:1808-1.812, 2002 13. Miyagishima RT, Brnrnwell ML, Jamieson EWR, et al: Tricuspid valve replacement using a eryopreserved mitral homograft. Surgical teeh nique and initial results. J Heart Valve Dis 9:805-808, 2000 14. Hvass U, Baron F, Fourchy D, et al: Mitral homografts for total tricuspid valve replacement: comparison of two techniques. J Thorac Cardiovasc Surg 212:592-594, 2001 From the Division of Cardiothoracie Surgery, The Johns Hopkins Hospital, Bahimore, MD, and LDS Hospital, Salt Lake City, UT. Address reprint requests to Donald B. Doty, M1), 324 Tenth Avenue, Salt Lake City, Utah 84103; e-mail: [email protected] 9 2003 Elsevier Inc. All rights reserved. 1522-2942/03/0804-0007530.00/0 doi:10, l O53/S1522-9042(O3)OOO44-X
O
leaflet
and lodged in the right ventricle. Rheumatic heart disease may affect the tricuspid valve in conjtmction with other cardiac valves. 1 The morphology is valve leaflet thickening and retraction with commissural fusion resulting in tricuspid valve stenosis and/or regurgitation. Carcinoid tumors producing serotonin (t-hydroxytryptamine) may destroy the tricuspid valve (and pulmonary valve) by cicatricial changes in leaflet tissues causing tricuspid stenosis and regurgitation.2 Similar changes are seen in patients using phentermine-fenfloramine for appetite control. Tricuspid valve regurgitation, commonly associated with cardiac transplantation,3 may become severe when associated with ruptured chordae tendinae from multiple right heart biopsies. There are some tricuspid valves affected by Ebstein's anomaly40z that are so severely deformed that repair is either ineffective or impossible so that valve replacement is necessary. Methods of tricuspid valve replacement are detailed in this paper.
Coronary sinus
| Tricuspid valve replacement with mechanical or stented bioprosthetic valve. Tricuspid valve operations are performed via a standard midline sternotomy (complete or lower one half) or through an anterior thoracotomy on the right side. Cardiopulmonary bypass is established using two cannulae for venous uptake (inset figure) with oxygenated blood returned to a cannula placed in the ascending aorta. Tourniquets are secured around the vena cavae and cannulae to isolate the right atrium. Some operations lend well to continuous coronary perfusion, but most procedures are performed with the aorta occluded and the heart arrested by cold cardioplegic solution administered through a catheter in the coronary sinus. The tricuspid valve is excised beginning with the anterior leaflet, continuing around the posterior leaflet, and finally completing the excision over the septal leaflet. Nearly all or at least a considerable rim of the septal leaflet of the tricuspid valve should be preserved for attachment of the valve prosthesis. The appropriate size valve prosthesis is selected based on measurements using valve anulus calibrators. Operative Techniques in Thoracic and Cardiovascular Surgery, Vol 8, No 4 (November), 2003: pp 193-200
193
Septal leaflet
Atri0ventricular node
uoronary sinus
2 Pledger reinforced mattress sutures are used to buttress and strengthen the tissue repair of the septal leaflet of the tricuspid valve. The stitches are placed through only leaflet tissue at the apex of the triangle of Koch to preserve the integrity and function of" the electrical conduction system. The rest of septal portion of the anulus is repaired by pledger-reinforced sutures passed around the anulus and leaflet remnant. The sutures are passed through the sewing ring of the prosthesis as the stitches are placed in the septal leaflet.
Tricuspid valve anulus
3 The prosthesis is attached to the rest of the anulus by continuous stitches using 2/0 polypropylene suture material. The continuous suture is started as a pledget-reinforced mattress stitch placed around the anulus anteriorly and brought through the sewing ring of the prosthesis. The prosthesis is placed in the right ventricle and the suture tightened to approximate the sewing ring of the prosthesis to the valve annulus. Stitches are placed from the anulus to the sewing ring of the prosthesis, worldng in a clockwise fashion. Tension is n|aintained on the suture to approximatel the tissues firmly to the sewing ring of the prosthesis. Tension is released with each needle pass to facilitate exposure of the junction of ventricular myocardium and the anulus.
195
TRICUSPID VALVE REPLACEMENT
Tricuspid valve anulus
-~i
~'
~=s 7i7 i:i=
W ~S
iI)IIIIII!IIIIIIIIIII(
R 2;" i7
J
4 The stitches are continued to the junction of the anulus of the free wall with the septum. The remainder of the repair is done using the needle at the opposite end of the suture working in a counterclockwise fashion. The needle is passed from the tricuspid anulus to the sewing ring of the prosthesis, continuing to the commissure between septal and anterior leaflets.
/~"/
iii ,:,i: ~ ~i? I ii~ ii~ii:i i
Atriow node
Completed repair 5 The valve replacement is completed by tying sutures securely. An alternate technique involves using all interrupted pledgeted mattress stitches when the tricuspid leaflet tissue and annulus is delicate and not as likely to hold secure with continuous suture technique.
Mitral valv~ homograft
6 Tricuspid valve replacentent with mitral valve homograft. The tricuspid valve is excised and the diameter of the anulus is measured as described above. A mitral valve homograft of the salne anular diameter is chosen. The homograft is cryopreserved and must be thawed, a process that takes approximately 20 minutes. The homograft is trimmed after thawing. The myocardium of the atrium and the ventricle is cut away from the anulus of the homograft, leaving just enough tissue to allow needle penetration without entering leaflet tissue The papillary muscles are shortened, leaving l0 mm of muscle below the chordal attachments.
Tricuspid valve anulus
Atr~ node
Anterior papillary muscle
. . . . . . . .
]
sinus
7 Horizontal mattress stitches (2/0 braided polyester) for auuloplasty are placed through the annlus of the tricuspid valve except for the area occupied by the septal leaflet. These stitches are placed using both needles of a double needle suture passed from the right ventricle to the right atrium through the tricuspid valve anulus. The sutures are placed as the initial step of the operation, as it is easier than after the homograft is in place, exposure is enhanced, and this cml be performed during the homograft thawing process. The anterior papillary muscle of the tricuspid valve is the only one suitable for attachment of the homograft papillary muscle. This papillary muscle supports all of the anterior and part of the posterior leaflets of the tricuspid valve, is usually of good size, and is continuous with the moderator band, which can provide additional support.
Septal leaflet M tri
8 The mitral homograft is oriented with its anterior leaflet to the ventricular septum (septal leaflet area of the tricuspid valve). Orientation is maintained by placing a stitch of 4/0 polypropylene through the fibrous trigones at each end of the homograft anterior leaflet and passing the stitches through recipient tricuspid valve anulus or leaflet remnant at each end of the septal leaflet.
198
DOTY AND DOTY
The anterior papillary muscle of the mitral homograft is positioned side-by-side to the anterior papillary muscle of the recipient tricuspid valve using a horizontal mattress stitch (inset figure). Firm attachment of the donor papillary muscle to the patient papillary muscle is accomplished using 8 to 10 simple stitches of fine monofilament suture (5/0 CardionylTM). A channel is made through the anterior wall of the right ventricle at an appropriate position to accommodate the posterior papillary muscle of the homograft. The papillary muscle is pulled through the channel. It is secured to the epicardial surface of the right ventricle with multiple stitches of 5/0 Cardionyl TM suture. The homograft papillary muscle is also secured to the endocardial surface with multiple sutures.
kl I L ~ ! I U I
~.apillary muscle
~L
Tricuspid valve anulus jJ
.:S
Mitral valve homograft
~I ~ "
][ O The anulus of the homograft is attached to the anulns of the recipient by continuous stitches of 4/0 polypropylene sutures using the stitches previously placed in the fibrous trigones of the homograft. The stitches are placed around the anulus of the patient tricuspid valve and through the atrial remnant and anulus of the homograft.
At~ fig
Completed repair ....... .... ][ ][ An anuloplasty band (Cosgrove Anuloplasty Band TM, Edwards LifeSciences, Anaheim, CA) or pericardial strip is used to support the tricuspid anulus in the portions occupied by the anterior and posterior leaflets. The septal portion is not supported. The anuloplasty band is attached to the tricuspid valve anutus by the previously placed mattress sutures. The anuloplasty band is tied securely to the tricuspid anulus to complete the valve replacement.
|~ 2
Photograph of tricuspid valve replacement with mitral valve homograft supported by Cosgrove Anuloplasty Band TM.
200
DOTY AND DOTY
COMMENTS Replacement of the tricuspid valve is not often required but there are some conditions in which the valve leaflet tissue is deficient or even destroyed to a degree that valve repair is not possible. Operations on the tricuspid valve are usually done concomitantly with operations on other c a r d i a c valves. Isolated tricuspid valve replacement is a high risk procedure with 30-day hospital mortality in the range of 10% to 24%.6-a Complete heart block requiring pacemaker insertion as a complication of tricuspid valve replacement occurred in 28% of 32 patients reported by Do and associates. 9 Choice of replacement device is not conclusive. Significant advantage has not been demonstrated comparing mechanical prostheses to stent-mounted bioprostheses.7,8,1~ Tricuspid valve replacement with mitral valve homograft may offer some advantages in patients with tricuspid valve endocarditis, ~2-~4 especially those infected with drugresistant bacteria or fungus.
REFERENCES 1. Roguin A, Rinkevich D, Marldewica W, et al: Long-term follow-up of patients with severe rheumatic tricuspid stenosis. Am Heart J 136:103108, 1998 2. Connolly HM, Schaff HV, Mullany CJ, et al: Carcinoid heart disease: Impact of pulmonary valve replacement in right ventricular function and remodeling. Circulation 106:I51 I56, 2002, (suppl) 3. Chan MC, Giannetti N, Kato T, et al: Severe tricuspid regurgitation after heart transplantation. J Heart Lung Transplant 20:709-717, 2001
4. Kiziltan HT, Theodoro DA, Warnes CA, et al: Late results of biopros thetic tricuspid valve replacement in EbsteiJa'S anomaly. Ann Thorac Surg 66:1539-1545, 1998 5. Renfu Z, Zengwei W, Hongyu Z, et al: Experience in corrective surgery for Ebstein's anomaly in 139 patients. J Heart Valve Dis 10:396-398, 2001 6. Dalrymple-Hay MJ, Leung Y, Ohri SK, et al: Tricuspid valve replacement: bioprostheses are preferable. J Heart Valve Dis 8:644648, 1999 7. Ratnatunga CP, Edwards MB, Dore CJ, et al: Tricuspid valve replacement: UK Heart Valve Registry mid term results comparing mechanical and biological prostheses. Ann Thorac Surg 66:19401947, 1998 8. Kaplan M, Kut MS, Demirtas MM, et al: Prosthetic replacement of tricuspid valve: bioprosthetie or mechanical. Ann Thorae Surg 73:467473, 2002 9. Do QB, Pellerin M, Carrier M, et al: Clinical outcome after isolated tricuspid valve replacement: 20-year experience. Can J Cardiol 16:489493, 2000 10. Rizzoli G, De Perini L, Bottio T, et al: Prosthetic replacement of the tricuspid valve: biological or mechanical? Ann Thorae Surg 66:$62-$67, 1998, (suppl) 11. Ohata T, I~igawa I, Tohda E, et al: Comparison of durability of bioprostheses in tricuspid and mitral positions. Ann Thorae Surg 71: $240-$243,2001, (suppl) 12. Couetil JP, Argyriadis PG, Shafy A, et al: Partial replacement of the tricuspid valve by mitral homografts in acute endoearditis. Ann Thorae Surg 73:1808-1.812, 2002 13. Miyagishima RT, Brnrnwell ML, Jamieson EWR, et al: Tricuspid valve replacement using a eryopreserved mitral homograft. Surgical teeh nique and initial results. J Heart Valve Dis 9:805-808, 2000 14. Hvass U, Baron F, Fourchy D, et al: Mitral homografts for total tricuspid valve replacement: comparison of two techniques. J Thorac Cardiovasc Surg 212:592-594, 2001 From the Division of Cardiothoracie Surgery, The Johns Hopkins Hospital, Bahimore, MD, and LDS Hospital, Salt Lake City, UT. Address reprint requests to Donald B. Doty, M1), 324 Tenth Avenue, Salt Lake City, Utah 84103; e-mail: [email protected] 9 2003 Elsevier Inc. All rights reserved. 1522-2942/03/0804-0007530.00/0 doi:10, l O53/S1522-9042(O3)OOO44-X