JTCS Sign the Guestbook
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

This Article
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
Georges Fayad
Henri Warembourg
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Fayad, G.
Right arrow Articles by Warembourg, H.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Fayad, G.
Right arrow Articles by Warembourg, H.

J Thorac Cardiovasc Surg 2005;130:1208-1210
© 2005 The American Association for Thoracic Surgery

Brief Communication

The "clover technique" as a new approach for correction of postendocarditic severe tricuspid valve regurgitation

Georges Fayad, MD a , * , Thomas Modine, MD a , Pierre-Vladimir Ennezat, MD b , Thierry Le Tourneau, MD, PhD a , Benoît Larrue, MD a , Richard Azzaoui, MD a , Olivier Nugue, MD b , Olivier Leroy, MD c , Christophe Decoene, MD a , Philippe Asseman, MD b , Henri Warembourg, MD a

a Cardiovascular Surgery Department, Hôpital Cardiologique, Lille, France
b Intensive Care Unit, Hôpital Cardiologique, Lille, France
c Infectious Diseases Regional Department, CH Tourcoing, France.

* Address for reprints: Georges Fayad, MD, Hôpital Cardiologique, 59037 Lille Cedex, France. (Email: g-fayad{at}chru-lille.fr).

Various surgical treatments applied to tricuspid endocarditis provide immediate satisfactory results but seem to offer poor midterm results. We here report the use of the clover technique 1 Go as a good alternative.

Patient and Methods

A 31-year-old male patient with a history of intravenous heroin addiction and active hepatitis C was admitted in a septic status with consciousness disorder and acute respiratory insufficiency.

A full-body scan revealed several pulmonary and splenic abscesses. Transesophageal echocardiographic findings showed massive vegetation on the mitral valve posterior commissure (Figure 1, A) with a grade II mitral valve incompetence. There were several vegetations on the tricuspid valve with a grade II leak. Hemocultures had revealed a meti-R Staphylococcus aureus. Intravenous antibiotic treatment with cefotaxime, fosfomycin, rifampicin, and fluconazole was initiated. A positive pulmonary and biologic outcome was observed rapidly. On the contrary, echocardiographic features worsened, with increasing mitral vegetation and grade IV mitral leak together with a grade IV tricuspid leak caused by total dehiscence of the anterior cusp. With respect to this development, we decided to operate.


Figure 1
View larger version (85K):
[in this window]
[in a new window]
  		Figure 1. Mitral valve view. A, Massive vegetation on the posterior commissure. B, Restoration of the posterior commissure with a pericardial patch, with good competence.

 
The intervention was performed under extracorporeal circulation at 33°C. The mitral valve was approached through a left atriotomy with resection of the posterior commissure and A3 and P3 sections and restoration of this area with a pericardial patch sutured to the posterior papillary muscle with a 4-0 polytetrafluoroethylene thread (Gore-Tex; W. L. Gore & Associates, Inc, Flagstaff, Ariz), producing satisfactory results (Figure 1, B).

Analysis of the tricuspid valve confirmed dehiscence of the anterior cups and the absence of vegetations. We performed an annuloplasty according to the clover technique 1 Go reinforced with an MC3 Edwards ring no. 36 (Edwards Lifesciences, Irvine, Calif; Figure 2).


Figure 2
View larger version (101K):
[in this window]
[in a new window]
  		Figure 2. Tricuspid valve view. A, Clover technique. Arrows indicate the 3 functional orifices. B, A prosthetic annuloplasty ring was used, providing good competence.

 
Perioperative transesophageal echocardiography confirmed satisfactory results.

The postoperative course was uneventful, with continuation of the intravenous antibiotic treatment for 3 weeks, followed by oral delivery of rifampicin and pristinamycin (Pyostacine) for a further 3 weeks. The valve culture was sterile.

At the 6-month follow-up, the patient was in good general condition and in New York Heart Association functional class I, and no mitral or tricuspid leak was observed at echocardiography. Mean gradients were 6 and 4 mm Hg for the tricuspid and mitral valves, respectively. An exercise test was carried out, confirming a good cardiovascular tolerance to effort.

Discussion

Tricuspid valve endocarditis benefits from antibiotic treatment with generally satisfactory results. 2 Go Medical treatment is preferred because of the poor midterm results obtained with various surgical options. In this case report the surgical approach was considered because of major tricuspid incompetence associated with mitral endocarditis with very mobile voluminous vegetation.

Several technical possibilities are conceivable when facing such complex lesions. Arbulu and colleagues 3 Go suggest a tricuspid valvulectomy without prosthetic replacement; however, late results are consistent with the development of severe right heart failure, with a frequent need for late reoperation. This technique's benefit is to cure the infection.

The second option is tricuspid prosthetic replacement. These prostheses are exposed to a serious infectious risk, as well as to dehiscence and thrombosis. 4 Go

Hence the use of mitral homografts 5 Go as an alternative with mitigated results. Procurement difficulties and the need for an important surgical know how make this solution very difficult and nonreproducible.

On the contrary, the clover technique is an easy and reproducible technique. 1 Go This procedure was described in case of tricuspid valve traumatic lesions. 1,6 Go Native valve preservation offers a better resistance to infection.

We have already applied this technique in 3 cases of tricuspid endocarditis with complex lesions and obtained very satisfactory results. In these generally fragile patients, the clover technique seems a very good alternative. A long-term follow-up is obviously mandatory.

References

  1. 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.[Abstract/Free Full Text]
  2. Hecht SR, Berger M. Right-sided endocarditis in intravenous drug users. Prognostic features in 102 episodes. Ann Intern Med 1992;117:560-566.[Abstract/Free Full Text]
  3. Arbulu A, Holmes RJ, Asfaw I. Surgical treatment of intractable right-sided infective endocarditis in drug addicts. 25 years experience. J Heart Valve Dis 1993;2:129-137.[Medline]
  4. McGrath LB, Gonzalez-Lavin L, Bailey BM, Grunkemeier GL, Fernandez J, Laub GW. Tricuspid valve operations in 530 patients. Twenty-five-year assessment of early and late phase events. J Thorac Cardiovasc Surg 1990;99:124-133.[Abstract]
  5. Mestres CA, Miro JM, Pare JC, Pomar JL. Six-year experience with cryopreserved mitral homografts in the treatment of tricuspid valve endocarditis in HIV-infected drug addicts. J Heart Valve Dis 1999;8:575-577.[Medline]
  6. Navia JL, Atik FA, Vega PR, Garcia M, Starling RC, Gonzalez-Stawinski GV, et al. Tricuspid valve repair for biopsy-induced regurgitation in a heart transplant recipient. J Heart Valve Dis 2005;14:264-267.[Medline]




This Article
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
Georges Fayad
Henri Warembourg
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Fayad, G.
Right arrow Articles by Warembourg, H.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Fayad, G.
Right arrow Articles by Warembourg, H.

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
ANN THORAC SURG ASIAN CARDIOVASC THORAC ANN EUR J CARDIOTHORAC SURG
J THORAC CARDIOVASC SURG ICVTS ALL CTSNet JOURNALS