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SURGICAL TECHNIQUE ___________________________________________________________
Anterior and Posterior Leaflets Augmentation to Treat Tricuspid Valve Regurgitation Andrea Quarti, M.D., Federica Iezzi, M.D., Elli Soura, M.D., Massimo Colaneri, M.D., and Marco Pozzi, F.R.C.S. Department of Pediatric and Congenital Cardiac Surgery and Cardiology, Ospedali Riuniti, Ancona, Italy ABSTRACT In congenital non-Ebstein anomalies of the tricuspid valve, the septal leaflet is often involved and tethered. We describe a standardized approach to address septal leaflet tethering by concomitant augmentation of the anterior and posterior leaflets. doi: 10.1111/jocs.12482 (J Card Surg 2015;30:421–
423) Isolated congenital non-Ebstein tricuspid regurgitation is a rare anomaly including a wide spectrum of anatomical conditions in which usually both leaflets and chordae are involved. The tricuspid valve is characterized by severe leaflet tethering, high coaptation depth and severe annular dilatation. Many techniques have been described to repair this condition which seeks to increase the leaflet coaptation either by reducing annular size, increasing the leaflet height, or acting on the subvalvar apparatus. We describe an approach to correct septal tethering by augmentation of both the anterior and posterior leaflets. SURGICAL TECHNIQUE In the last three years, seven patients have been referred with a non-Ebstein tricuspid valve regurgitation of congenital origin. Among them, four patients (mean age 32 years, range 17–48 years, mean BSA 1,72 m2) had primary severe tricuspid valve regurgitation due to septal leaflet tethering. Preoperative echocardiographic examination showed an enlarged annulus with a mean diameter of 43 mm (mean Z-score þ 1.87). Mean coaptation depth was 15 mm. Despite a dilated right ventricle, none of the patients presented with ventricular dysfunction and they were all in NYHA class II.
Conflict of interest: The authors acknowledge no conflict of interest in the submission. Address for correspondence: Andrea Quarti, M.D., Department of Pediatric and Congenital Cardiac Surgery and Cardiology, Ospedali Riuniti, Via Conca 71, 60126 Ancona, Italy. Fax: þ39.071.5965360, e-mail: [email protected]
Surgical access was through a median sternotomy or right anterior minithoracotomy (two patients). All patients received a 32 mm ring annuloplasty and a concomitant anterior and posterior leaflet augmentation. A patch of autologous pericardium was harvested as an oval shape in three patients and in one a Cormatrix patch was preferred (Cormatrix Cardiovascular Atlanta, GA, USA), because of thickening of autologous pericardium. The patch was trimmed using the same measure of the annular tricuspid ring chosen, a 32 mm Carpentier–Edwards ring (Edwards Lifesciences LLC, Irvine, CA, USA). Under cardiopulmonary bypass and aortic cross clamping, the anterior and the posterior leaflets were detached from the annulus from the antero-septal commissure to the postero-septal commissure (Fig. 1). The ventricular aspect of the leaflets was inspected in order to remove secondary chordae and reduce the risk of restricted leaflet motion; finally the patch was sutured in to fill the gap. Care has to be taken in the antero-posterior commissure where the leaflet height is minimal. The anterior and posterior leaflets can be detached one from the other and in this case they must be reattached to the patch next to each other to reconstitute the commissure. The ring was then implanted on a beating heart. All patients had no residual tricuspid regurgitation and none had any complications. At a mean follow-up of 16 months (range 12–23 months) all patients are in NYHA class I and none of them has tricuspid regurgitation. The coaptation depth didn’t improve significantly (mean 13 mm), but the coaptation length increased up to a mean value of 7.3 mm (range 6.1–8.6 mm). The postoperative echocardiography showed billowing of the patch through the valve orifice and the complete
QUARTI ET AL. TRICUSPID LEAFLETS AUGMENTATION
J CARD SURG 2015;30:421–423
Figure 1. The leaflets are detached from the annulus (A). The patch augmentation of the anterior and posterior leaflets produces a downward displacement of the free edge of the newly created antero-posterior leaflet (B).
occlusion of the tricuspid annulus. The reconstructed antero-posterior leaflet was displaced down into the ventricle and it formed the coaptation surface with the fixed and retracted septal leaflet, on a new coaptation plane (Fig. 2).
Figure 2. The leaflets are detached from the annulus from the antero-septal commissure to the postero-septal commissure (A). At the end of the repair the orifice of the valve is closed almost entirely by the patch (B).
Comment Tricuspid regurgitation has been treated with heterogeneous techniques, primarily described for secondary tricuspid valve regurgitation, with an early recurrence of regurgitation described to be as high as 15–30%.1 Annular dilation can be addressed using a ring annuloplasty2; however when there is leaflet tethering and high coaptation depth this surgical solution may be inadequate. Correction of tethered leaflet in functional tricuspid disease has been proven to be successful by Dreyfus3 by augmentation of the anterior leaflet alone. Other techniques have been described as the bicuspidalization of the tricuspid valve and the clover technique.4,5 However these techniques do not address the issue of anterior and posterior leaflet tension and could induce restricted leaflet motion. We chose to extend both the anterior and posterior tricuspid leaflets. In our series, the patch was always tailored according to the annuloplasty ring sizer and the ring was never smaller than 32 mm. A small ring with a large patch could create tricuspid valve stenosis since the leaflet surface is almost doubled at the end of the repair. The accordance of the ring and the patch size was an easy way to create a competent valve. (Fig. 3) After leaflet augmentation, the coaptation free edge of the reconstructed antero-posterior leaflet is moved towards the right ventricle, in a new coaptation plane. The coaptation is unchanged after the repair but the coaptation length was significantly increased. The anatomical tricuspid orifice, at the end of the repair, is closed by the patch which inflates during right ventricle systole and bulges across the annular ring, without any signs of infundibulum occlusion during diastole. The valve changes paradoxically from tricuspid to monocuspid with the saillike reconstructed antero-posterior leaflet. Furthermore
J CARD SURG 2015;30:421–423
QUARTI ET AL. TRICUSPID LEAFLETS AUGMENTATION
Figure 3. Severe tricuspid valve regurgitation with leaflet tethering, high coaptation depth, and large regurgitant jet (A). The patch inflates and occludes the tricuspid valve orifice (B).
the concomitant augmentation of the anterior and posterior leaflets significantly reduces the risk of a residual regurgitant jet at the postero-septal commissure. This repair technique is also easy to perform under minimally invasive conditions. Mid-term and long-term results are lacking and this is a limitation of our study, but early results are encouraging for the lack of tricuspid regurgitation. REFERENCES 1. McCarthy PM, Bhudia SK, Raeswaran J, et al: Tricuspid valve repair: Durability and risk factors for failure. J Thorac Cardiovasc Surg 2004;127:674–685.
2. Guenther T, Mazzitelli D, Noebauer C, et al: Tricuspid valve repair: Is ring annuloplasty superior? Eur J Cardiothorac Surg 2013;43(1):58–65. 3. Dreyfus GD, Raja SG, Chan KMJ. Tricuspid leaflet augmentation to address severe tethering in functional tricuspid regurgitation. Eur J Cardiothorac Surg 2008;34: 908–910. 4. Ghanta RK, Chen R, Narayanasamy N, et al: Suture bicuspidization of the tricuspid valve versus ring annuloplasty for repair of functional tricuspid regurgitation: Mid term results of 237 patients. J Thorac Cardiovasc Surg 2007;133:117–126. 5. Alfieri O, De Bonis M, Lapenna E, et al: The ‘‘clover technique’’ as a novel approach for correction of posttraumatic tricuspid regurgitation. J Thorac Cardiovasc Surg 2003;126(1):75–79.