doi:10.1510/mmcts.2007.002790
Valve repair for traumatic tricuspid regurgitation S. Chris Malaisriea,*, Edwin McGeea, Richard Leea, Patrick M. McCarthya, Gideon Cohenb a
Division of Cardiothoracic Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA b
Division of Cardiothoracic Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada Tricuspid regurgitation is a rare complication of blunt thoracic trauma. Due to subtle clinical manifestation in the presence of multi-organ trauma, the condition may not be recognized at the time of injury. Chronic tricuspid regurgitation is well tolerated, particularly in the young patient, and can go undiagnosed for years until the onset of right ventricular failure. The majority of patients will undergo tricuspid valve replacement, but tricuspid valve repair can be an alternative strategy for selected patients.
Keywords: Trauma; Tricuspid valve; Tricuspid regurgitation; Valve repair Introduction Traumatic tricuspid regurgitation is a rare complication of blunt thoracic trauma, most commonly following high-speed motor vehicle collisions. The transmission of sudden compressive force to the heart during late diastole or early systole can result in ruptured chordae tendinae, ruptured papillary muscles, or leaflet tears. The anterior leaflet or its corresponding subvalvar apparatus is most commonly injured (Photo 1) w1x. Isolated traumatic tricuspid regurgitation is well-tolerated and may go undiagnosed for years until the onset of right heart failure.
Surgical technique A full sternotomy offers the best exposure for repair of the tricuspid valve and gives the most flexibility for cannulation (Videos 1–3). Alternatively, a minimallyinvasive approach can be used. Through a limited skin incision and partial sternotomy, the right atrium can be exposed adequately (Video 4). Femoral cannulation * Corresponding author. Division of Cardiothoracic Surgery, Northwestern University, 201 East Huron St, Galter Pavilion 11-140, Chicago, IL 60611, USA. Tel.: q1-312-695 2517; fax: q312-695 1903. E-mail: [email protected] 䉷 2008 European Association for Cardio-thoracic Surgery
for cardiopulmonary bypass can minimize the amount of clutter, leaving a single superior vena cava cannula in the operative field. Because the repair is performed on an empty beating heart, there is no need to contend with an aortic cross-clamp or cardioplegia catheters. Inspection of the tricuspid valve typically reveals a flail segment in the anterior leaflet (Video 5). This segment can be resected and the leaflet repaired similar to mitral valve repair techniques (Video 6). A tricuspid annuloplasty ring (Edwards MC3 – MMCTSLink 162) is placed to reduce the annulus in the setting of annular dilatation secondary to long-standing tricuspid insufficiency (Video 7). Saline distention of the right ventricle to test the competency of the repaired valve is facilitated by occluding the pulmonary artery with a sponge stick (Video 8).
Results Our experience with one patient with traumatic tricuspid regurgitation shows acceptable results with this repair technique. No residual tricuspid regurgitation was seen on completion transesophageal echocardiography prior to leaving the operating room (Video 9). The partial sternotomy healed without complication 1
S.C. Malaisrie et al. / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2007.002790
Video 3. Cannulating the heart. The femoral artery is cannulated for arterial inflow. The femoral vein is cannulated, placing the tip of the cannula into the inferior vena cava. The superior vena cava is directly cannulated in the chest. Caval tourniquets are used to allow for right heart isolation.
Photo 1. Transesophageal echocardiogram from midesophagus 45-degree angle showing flail anterior tricuspid valve leaflet caused by blunt thoracic trauma. (Reproduced from Ref. w1x with permission from Elsevier Inc.) Video 4. Examination of the tricuspid valve. Following initiation of total cardiopulmonary bypass, a right atriotomy is made. Inspection of the tricuspid valve reveals ruptured chordae tendinae of the anterior leaflet.
Video 1. Performing the sternotomy. A partial lower sternotomy can be performed instead of a full sternotomy in most cases. An oscillated sternal saw facilitates entry.
Video 5. Resection of the flail segment of the anterior leaflet. After identifying the flail segment of the anterior leaflet, a partial resection is performed.
Video 2. Exposing the heart. A small sternal retractor is used. Pericardial sutures are placed to bring the heart anterior into the field. These sutures are placed on tension with the retractor removed.
and the limited skin incision was cosmetically-pleasing. On follow-up the patient was without symptoms indicative of a durable repair.
Discussion Traumatic tricuspid regurgitation is a rare sequela of blunt thoracic trauma. Approximately 100 cases have been described in the literature, most being single case reports w2x. Despite the severity of valve damage and interval to diagnosis, 2
Video 6. Repair of the anterior leaflet with annular plication and reapproximation of leaflet. The gap in the annulus is plicated using a pledgeted 2-0 braided polyester suture. The leaflet edges are reapproximated with two rows of running 5-0 braided polyester suture.
most authors report success with valve repair in selected cases, avoiding the need for a prosthetic valve in the tricuspid position. The largest published series of traumatic tricuspid regurgitation is from the Mayo Clinic w3x. In this single
S.C. Malaisrie et al. / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2007.002790
Video 7. Placement of a tricuspid annuloplasty ring (Edwards MC3). Following placement of interrupted 2-0 braided polyester sutures into the tricuspid annulus, carefully avoiding the conduction system in the Triangle of Koch, a standard band annuloplasty is performed.
Video 8. Testing of the repaired tricuspid valve. The right ventricle is filled with fluid to test the tricuspid valve repair. The pulmonary artery can be occluded during this maneuver to facilitate pressurization of the right ventricle.
traction and atrophy of the subvalvar apparatus over time. In another series from the Milan group, five patients had a valve repair using a technique similar to the edge-to-edge repair of the mitral valve also described by the same authors w4x. With this technique all three leaflet edges are approximated creating a tricuspid valve with three orifices. Patients were left with either trace or no tricuspid regurgitation. No patients had tricuspid stenosis. In the most recent published series from Beijing w5x 10 patients underwent surgery for traumatic tricuspid regurgitation. Of these patients, five underwent a ‘double-orifice technique’ with ring annuloplasty. Long-term follow-up from 8 to 36 months revealed trivial tricuspid regurgitation in four patients and no tricuspid regurgitation in one. Overall, repair of traumatic tricuspid regurgitation is possible using well-known techniques used in mitral valve repair. Results from one single-center study indicate that durability is satisfactory up to a mean followup of 12 years w3x. The repair technique described here is just one of many techniques that have been successfully employed and described in the literature.
References
Video 9. Completion transesophageal echocardiogram showing competent tricuspid valve after successful repair. The right atriotomy is closed and cardiopulmonary is discontinued. Post-repair echocardiography shows a competent tricuspid valve.
center series, 13 patients underwent surgery for tricuspid regurgitation. Of these patients, five had a valve repair and eight had a valve replacement. Conclusions of this study were that both valve repair and replacement achieved good functional results over a median follow-up of 12 years. However, the authors caution that valve repair may not be possible in patients with a remote history of trauma due to con-
w1x Nelson M, Wells G. A case of traumatic tricuspid valve regurgitation caused by blunt chest trauma. J Am Soc Echocardiogr 2007;20:198 e4–5. w2x Turkoz R, Gulcan O, Atalay H, Uguz E. Surgical repair of tricuspid valve regurgitation caused by blunt thoracic trauma. J Trauma 2007;63:E7–9. w3x 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. w4x 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. w5x Luo GH, Ma WG, Sun HS, Xu JP, Sun LZ, Hu SS. Correction of traumatic tricuspid insufficiency using the double orifice technique. Asian Cardiovasc Thorac Ann 2005;13:238–240.
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Valve repair for traumatic tricuspid regurgitation S. Chris Malaisriea,*, Edwin McGeea, Richard Leea, Patrick M. McCarthya, Gideon Cohenb a
Division of Cardiothoracic Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA b
Division of Cardiothoracic Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada Tricuspid regurgitation is a rare complication of blunt thoracic trauma. Due to subtle clinical manifestation in the presence of multi-organ trauma, the condition may not be recognized at the time of injury. Chronic tricuspid regurgitation is well tolerated, particularly in the young patient, and can go undiagnosed for years until the onset of right ventricular failure. The majority of patients will undergo tricuspid valve replacement, but tricuspid valve repair can be an alternative strategy for selected patients.
Keywords: Trauma; Tricuspid valve; Tricuspid regurgitation; Valve repair Introduction Traumatic tricuspid regurgitation is a rare complication of blunt thoracic trauma, most commonly following high-speed motor vehicle collisions. The transmission of sudden compressive force to the heart during late diastole or early systole can result in ruptured chordae tendinae, ruptured papillary muscles, or leaflet tears. The anterior leaflet or its corresponding subvalvar apparatus is most commonly injured (Photo 1) w1x. Isolated traumatic tricuspid regurgitation is well-tolerated and may go undiagnosed for years until the onset of right heart failure.
Surgical technique A full sternotomy offers the best exposure for repair of the tricuspid valve and gives the most flexibility for cannulation (Videos 1–3). Alternatively, a minimallyinvasive approach can be used. Through a limited skin incision and partial sternotomy, the right atrium can be exposed adequately (Video 4). Femoral cannulation * Corresponding author. Division of Cardiothoracic Surgery, Northwestern University, 201 East Huron St, Galter Pavilion 11-140, Chicago, IL 60611, USA. Tel.: q1-312-695 2517; fax: q312-695 1903. E-mail: [email protected] 䉷 2008 European Association for Cardio-thoracic Surgery
for cardiopulmonary bypass can minimize the amount of clutter, leaving a single superior vena cava cannula in the operative field. Because the repair is performed on an empty beating heart, there is no need to contend with an aortic cross-clamp or cardioplegia catheters. Inspection of the tricuspid valve typically reveals a flail segment in the anterior leaflet (Video 5). This segment can be resected and the leaflet repaired similar to mitral valve repair techniques (Video 6). A tricuspid annuloplasty ring (Edwards MC3 – MMCTSLink 162) is placed to reduce the annulus in the setting of annular dilatation secondary to long-standing tricuspid insufficiency (Video 7). Saline distention of the right ventricle to test the competency of the repaired valve is facilitated by occluding the pulmonary artery with a sponge stick (Video 8).
Results Our experience with one patient with traumatic tricuspid regurgitation shows acceptable results with this repair technique. No residual tricuspid regurgitation was seen on completion transesophageal echocardiography prior to leaving the operating room (Video 9). The partial sternotomy healed without complication 1
S.C. Malaisrie et al. / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2007.002790
Video 3. Cannulating the heart. The femoral artery is cannulated for arterial inflow. The femoral vein is cannulated, placing the tip of the cannula into the inferior vena cava. The superior vena cava is directly cannulated in the chest. Caval tourniquets are used to allow for right heart isolation.
Photo 1. Transesophageal echocardiogram from midesophagus 45-degree angle showing flail anterior tricuspid valve leaflet caused by blunt thoracic trauma. (Reproduced from Ref. w1x with permission from Elsevier Inc.) Video 4. Examination of the tricuspid valve. Following initiation of total cardiopulmonary bypass, a right atriotomy is made. Inspection of the tricuspid valve reveals ruptured chordae tendinae of the anterior leaflet.
Video 1. Performing the sternotomy. A partial lower sternotomy can be performed instead of a full sternotomy in most cases. An oscillated sternal saw facilitates entry.
Video 5. Resection of the flail segment of the anterior leaflet. After identifying the flail segment of the anterior leaflet, a partial resection is performed.
Video 2. Exposing the heart. A small sternal retractor is used. Pericardial sutures are placed to bring the heart anterior into the field. These sutures are placed on tension with the retractor removed.
and the limited skin incision was cosmetically-pleasing. On follow-up the patient was without symptoms indicative of a durable repair.
Discussion Traumatic tricuspid regurgitation is a rare sequela of blunt thoracic trauma. Approximately 100 cases have been described in the literature, most being single case reports w2x. Despite the severity of valve damage and interval to diagnosis, 2
Video 6. Repair of the anterior leaflet with annular plication and reapproximation of leaflet. The gap in the annulus is plicated using a pledgeted 2-0 braided polyester suture. The leaflet edges are reapproximated with two rows of running 5-0 braided polyester suture.
most authors report success with valve repair in selected cases, avoiding the need for a prosthetic valve in the tricuspid position. The largest published series of traumatic tricuspid regurgitation is from the Mayo Clinic w3x. In this single
S.C. Malaisrie et al. / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2007.002790
Video 7. Placement of a tricuspid annuloplasty ring (Edwards MC3). Following placement of interrupted 2-0 braided polyester sutures into the tricuspid annulus, carefully avoiding the conduction system in the Triangle of Koch, a standard band annuloplasty is performed.
Video 8. Testing of the repaired tricuspid valve. The right ventricle is filled with fluid to test the tricuspid valve repair. The pulmonary artery can be occluded during this maneuver to facilitate pressurization of the right ventricle.
traction and atrophy of the subvalvar apparatus over time. In another series from the Milan group, five patients had a valve repair using a technique similar to the edge-to-edge repair of the mitral valve also described by the same authors w4x. With this technique all three leaflet edges are approximated creating a tricuspid valve with three orifices. Patients were left with either trace or no tricuspid regurgitation. No patients had tricuspid stenosis. In the most recent published series from Beijing w5x 10 patients underwent surgery for traumatic tricuspid regurgitation. Of these patients, five underwent a ‘double-orifice technique’ with ring annuloplasty. Long-term follow-up from 8 to 36 months revealed trivial tricuspid regurgitation in four patients and no tricuspid regurgitation in one. Overall, repair of traumatic tricuspid regurgitation is possible using well-known techniques used in mitral valve repair. Results from one single-center study indicate that durability is satisfactory up to a mean followup of 12 years w3x. The repair technique described here is just one of many techniques that have been successfully employed and described in the literature.
References
Video 9. Completion transesophageal echocardiogram showing competent tricuspid valve after successful repair. The right atriotomy is closed and cardiopulmonary is discontinued. Post-repair echocardiography shows a competent tricuspid valve.
center series, 13 patients underwent surgery for tricuspid regurgitation. Of these patients, five had a valve repair and eight had a valve replacement. Conclusions of this study were that both valve repair and replacement achieved good functional results over a median follow-up of 12 years. However, the authors caution that valve repair may not be possible in patients with a remote history of trauma due to con-
w1x Nelson M, Wells G. A case of traumatic tricuspid valve regurgitation caused by blunt chest trauma. J Am Soc Echocardiogr 2007;20:198 e4–5. w2x Turkoz R, Gulcan O, Atalay H, Uguz E. Surgical repair of tricuspid valve regurgitation caused by blunt thoracic trauma. J Trauma 2007;63:E7–9. w3x 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. w4x 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. w5x Luo GH, Ma WG, Sun HS, Xu JP, Sun LZ, Hu SS. Correction of traumatic tricuspid insufficiency using the double orifice technique. Asian Cardiovasc Thorac Ann 2005;13:238–240.
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