Tricuspid Valve Replacement with the Right Atrial Appendage Valve: The First Report
Advanced techniques in tricuspid valve repair have made it possible to preserve the tricuspid valve in most patients. However, there are still situations where replacement of the valve is required. The prosthetic valves have demonstrated a suboptimal function on the right side of the heart. The risk of mechanical valve thrombosis is higher on the right and structural valve degeneration, which is mostly caused by the immune response to the prosthetic biologic valve, and inevitably leads to reinterventions, accelerated in children and young adults. A native valve with a well-functioning architecture that can be constructed intraoperatively using the patient's own tissue may be an attractive alternative for right-sided valve replacement.
The right atrial appendage valve (RAA valve) was originally designed in 2018 for the right ventricular outflow tract in patients with tetralogy of fallot. The authors presented the technique in 2019 and published the short-term results in 2020 (1,2). The detailed technical video of RAA valve creation is available on CTSNet (3). Encouraging midterm results with 141 patients of the RAA valve in pulmonary position persuaded the research team to try to design the RAA valve to be used for tricuspid valve replacement as well. The team has demonstrated that the right atrial appendage tissue remains alive in its extraanatomical position. So far, unpublished evaluations are also in favor of growth in the RAA valve. There have been no signs of degeneration or calcification in our RAA valves in the pulmonary position so far. Based on these facts, it can be assumed that the RAA valve can also be a suitable alternative for tricuspid valve replacement.
The different structures of the pulmonic valve and the tricuspid valve require modification in the design of the valve if it will be used in the tricuspid valve position. Although, in principle, harvesting and preparation of the right atrial appendage is the same, the RAA lateral margins which make the commissures are easily sutured to the edges of the pulmonary arteriotomy, while in tricuspid valve position there are no cylindrical structures to support the commissures and the commissures should be suspended to the ventricular muscles by artificial chords. The length of these chords is of paramount importance, as they should prevent prolapse of the leaflets as well as being stretched excessively, which may cause tethering or rupture. The authors use the adjustable pericardial lock technique to fix the chordal length (4).
Essentially, this design resembles the cylinder technique, which has been used with good results (5). The valve in that technique is made using a CorMatrix patch cylinder connected directly to three papillary muscles. Here, the team used native appendage tissue and the valve was supported by two chords to the ventricular septal muscles. The size of the annulus, which is mostly dilated in these patients, should be adjusted to accommodate the existing right atrial appendage. If the RAA is not wide enough to match the minimum acceptable size of the annulus for the patient’s body surface area, the left atrial appendage can be added to the RAA to have enough tissue to cover the annulus circumference. However, this could make the procedure more complex, and the authors have no experience with that yet.
Although both downsizing the annulus and suturing the RAA valve to the annulus can fix the annulus size and prevent dilation, the authors prefer to use a semi-rigid annuloplasty ring to reshape the annulus for the best durable function of the valve.
This presentation is the first report of a successful novel tricuspid valve operation, both in terms of the native tissue used and the technical design applied. Nonetheless, a longer follow-up on a larger group of patients is needed to be able to comment on the ultimate reliability and long-term effectiveness of the technique.
1-Amirghofran AA Using Right Atrial Appendage (RAA) to prevent pulmonary insufficiency after Tetralogy of Fallot repair. First world report of RAA valve. The 33rd European Association for Cardio-Thoracic Surgery Annual Meeting; 2019 October 3-5; Lisbon, Portugal. (video presentation, abstract ID: 000559)
2-Amirghofran A, Edraki F, Edraki M, Ajami G, Amoozgar H, Mohammadi H, Emaminia A, Ghasemzadeh B, Borzuee M, Peiravian F, Kheirandish Z, Mehdizadegan N, Sabri M, Cheriki S, Arabi H. Surgical repair of tetralogy of Fallot using autologous right atrial appendages: short- to mid-term results. Eur J Cardiothorac Surg. 2021 Apr 13;59(3):697-704. doi: 10.1093/ejcts/ezaa374. PMID: 33164039.
3- Amirghofran AA, Nirooei E. How to Make a Valve for the RVOT from the Right Atrial Appendage. October 2022.
4- Amirghofran AA. Adjustable Pericardial Lock Technique for Complex Mitral Valve Repair. October 2019
5- Myers PO, Dave H, Kretschmar O, Sologashvili T, Pfister R, Prêtre R. Cylinder mitral and tricuspid valve replacement in neonates and small children. Eur J Cardiothorac Surg. 2020 Nov 1;58(5):964-968. doi: 10.1093/ejcts/ezaa196. PMID: 32844202.