Editorial comment on valve repair for traumatic tricuspid regurgitation Michele De Bonis, Ottavio Alfieri* Department of Cardiac Surgery, San Raffaele University Hospital, Via Olgettina 60, 20132 Milan, Italy In this chapter of the MMCTS, Malaisrie and coworkers describe a very interesting case of severe post-traumatic tricuspid regurgitation which was successfully corrected by resecting a flail segment of the anterior leaflet of the tricuspid valve w1x. A tricuspid annuloplasty ring (Edwards MC3) was used to treat the associated annular dilatation and stabilize the repair. No residual tricuspid regurgitation was present at the trans-esophageal exam performed before leaving the operating room. Although long-term echocardiographic follow-up is mandatory to confirm the durability of the repair, the Authors have to be congratulated for the excellent early result obtained in this patient in whom, in addition, they used a minimally invasive approach rather than a standard median sternotomy. Surgical correction of traumatic tricuspid regurgitation can be unpredictable and challenging. At the time of surgery it is not unusual to find multiple and different lesions involving the leaflets and the subvalvular apparatus, together with some degree of right ventricular dilatation and dysfunction. The leaflet resection technique, adopted in this case, was certainly a reasonable solution considering that the lesion encountered was represented by an isolated flail of the anterior leaflet. Nevertheless, in the presence of severe right ventricular dilatation, the application of this method can lead to significant residual regurgitation. In fact, in longstanding undiagnosed tricuspid insufficiency, the segmental flail initially caused by the blunt chest trauma is gradually followed by the development of tethering defects of the remaining portions of the valve due to the progressive enlargement of the right ventricular chamber. When this stage has been reached, resection of the flailing segment * Corresponding author. Tel.: q39-02-2643 7102; Fax: q41-022643 7125 E-mail: [email protected] 䉷 2008 European Association for Cardio-thoracic Surgery

alone does not address the restricted motion involving the remaining parts of the tricuspid valve resulting in inadequate coaptation and residual regurgitation. This is consistent with our initial clinical experience in this field which was characterized by some suboptimal surgical results that could possibly be explained by the above-mentioned mechanism w2x. Besides the possible dilatation and deterioration of the right ventricle, in post-traumatic tricuspid insufficiency, multiple lesions can be encountered simultaneously including leaflet tears, rupture of chordae tendineae, detachment of papillary muscles. Annular dilatation along with retraction and shortening of the subvalvular apparatus can progressively develop as well. Such an association of different pathologic conditions can make valve repair extremely difficult as demonstrated by a number of reports describing several unsuccessful attempts of reconstructive approaches eventually followed by valve replacement w3–5x. Considering the complexity of the mechanisms involved in traumatic tricuspid regurgitation, a variety of operative techniques needs to be considered and the surgical approach has to be tailored to the specific intraoperative findings. In most of cases the annulus is very dilated and has to be remodelled with an annuloplasty, preferentially with a ring. Leaflet tears, although rather uncommon, can be easily fixed with a suture or a pericardial patch. Conversely, chordal ruptures are more difficult to correct. When the lesion is represented by an isolated prolapse or flail without concomitant severe RV dilatation, leaflet resection can be effectively used as in the case here reported. Artificial chordae or chordal transposition represent other possible solutions although they can be more time consuming and technically demanding due to the flimsy nature of the tricuspid apparatus. In case of papillary muscle rupture, muscle reimplantation appears to be the most reasonable option provided that the correct 1

M. De Bonis and O. Alfieri / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2008.003251 site of reimplantation is clearly identified and no severe right ventricular dilatation has occurred in the meantime. Indeed, even a minimal displacement of the reimplanted papillary muscle can cause significant valve distortion and, if important right ventricular dilatation is present, muscle reimplantation, despite being performed correctly, may result in tethering of the related leaflets and lack of coaptation. Besides the anatomical repair provided by the above-mentioned surgical methods, a functional correction of traumatic tricuspid regurgitation can alternatively be achieved by using the so-called ‘clover’ technique. This method consists in stitching together the central part of the tricuspid leaflets, forcing their coaptation and producing a ‘clover shaped’ competent valve w6, 7x. The interest in this technique comes from the fact that it can be easily applied to both prolapsing and tethering defects either isolated or present in combination. In our experience it significantly increased the feasibility of tricuspid valve repair even in the presence of multiple lesions or dilatation of the right ventricle with excellent immediate and mid-term results. Certainly this technical solution, together with the more conventional surgical approaches mentioned before, should be part of the surgical armamentarium of every cardiac surgeon dealing with complex traumatic tricuspid insufficiency. The aim is to increase the likelihood of repair in such a way that early correction of traumatic tricuspid regurgitation can be recommended to relieve symptoms and prevent right ventricular dysfunction in these usually very young and otherwise fit patients.


References w1x Malaisrie SC, McGee E, Lee R, McCarthy PM, Cohen G. Valve repair for traumatic tricuspid regurgitation. Multimedia Man Cardiothorac Surg doi: 10.1510/mmcts.2007.002790. w2x Maisano F, Lorusso R, Sandrelli L, Torracca L, Coletti G, La Canna G, Alfieri O. Valve repair for traumatic tricuspid regurgitation. Eur J Cardiothorac Surg 1996;10:867–873. w3x Richard P, Vayre F, Sabouret P, Gandjbakhch I, Ollivier JP. Outcome of traumatic tricuspid insufficiency, treated surgically. Apropos of 9 cases. Arch Mal Coeur Vaiss 1997;90:451–456. w4x Holper K, Ha¨hnel C, Augustin N, Meisner H. Operative correction of traumatic tricuspid insufficiency. Herz 1996;21:172–178. w5x van Son JAM, Danielson GK, Schaff HV, Miller FA Jr. Traumatic tricuspid valve insufficiency. Experience in thirteen patients. J Thorac Cardiovasc Surg 1994;108:893–898. w6x Alfieri O, De Bonis M, Lapenna E, Agricola E, Quarti A, Maisano F. The ‘‘clover technique’’ as a novel approach for correction of post-traumatic tricuspid regurgitation. J Thorac Cardiovasc Surg 2003;126:75–79. w7x De Bonis M, Lapenna E, La Canna G, Grimaldi A, Maisano F, Torracca L, Caldarola A, Alfieri O. A novel technique for correction of severe tricuspid valve regurgitation due to complex lesions. Eur J Cardiothorac Surg 2004;25:760–765.

Editorial comment on valve repair for traumatic tricuspid regurgitation.

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