Complex Tricuspid Valve Repair

The tricuspid valve has historically received less attention than left-sided valves with regard to pathophysiology and surgical management. Functional regurgitation is the most common tricuspid valve disease secondary to dilatation of tricuspid annulus and/or tethering of valve leaflets from right ventricular dilatation and dysfunction. Recent data suggest that tricuspid regurgitation is not benign, and many patients will benefit from intervention at the time of left-sided valve surgery, or early in isolated tricuspid valve disease. Most cases can be treated with restrictive annuloplasty. However, this would not suffice for complex cases with extreme annular dilatation and/or leaflet tethering. For these conditions, techniques such as neorchordae and patch augmentation of diseased leaflets is sometimes necessary.

In this video, the authors demonstrate the step-by-step approach to perform septal leaflet augmentation and several neochordae that allowed for effective correction of severe tricuspid regurgitation with annular dilation and complex tethering of valve leaflets.

A 43-year-old man was referred to the authors’ department for severe isolated tricuspid regurgitation. He presented with dizziness without syncopial episodes or overt dyspnoea (NYHA I). He was found to have torrential TR with moderate RV dysfunction and mild LV dysfunction. He had a normal angiogram. On TOE, there was a dilated TV annulus (6.3 cm) with dilated RV (midcavity RV dimension 6.0 cm), severe prolapse of anterior leaflet with abnormal thickened chordae, and restriction of the septal leaflet, resulting in noncoaptation of the leaflets. There was no clear etiology, so it could have been congenital, but he does give a history of a high fall 4-5 months before operation.

A standard horizontal right atriotomy was performed. The ring stitches were placed first to expose the valve. The commissure between the posterior and septal leaflets was oversewn with running 5-0 prolene. The septal leaflet was detached from the annulus and a cardiocel neo patch was sutured with 5-0 prolene to extend the leaflet. A couple of tethering septal chordae were removed and replaced with CV4 Goretex sutures. The thickened and fused chordae of the anterior leaflet was reduced in length by folding it and securing it with 4-0 prolene. X3 CV4 were positioned in thickened areas of the RV, and then positioned symmetrically onto the anterior leaflet. A 32 mm tricuspid physio ring was positioned with interrupted 2-0 ethibond sutures. The operation was completed in a usual fashion. Intraoperative TOE showed a good result with trace regurgitation. The patient went home on the fifth postoperative day without complications. Routine follow-up was satisfactory with trace TR and improving RV dimension and function (midcavity diameter 5.2 cm) on echocardiography.

Isolated tricuspid valve repairs are rare and challenging cases require specialist expertise and a combination of treatment strategies. If performed successfully, patients perform well without the need for replacement with its associated risks of thrombosis and heart block.