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J Thorac Cardiovasc Surg 2009;137:e30-e32
© 2009 The American Association for Thoracic Surgery
Brief Communication |
a Division of Cardiac Surgery, University of Ottawa, Ottawa, Ontario, Canada
b Department of Epidemiology, University of Ottawa, Ottawa, Ontario, Canada
c Department of Pathology, University of Ottawa, Ottawa, Ontario, Canada
Received for publication March 6, 2008; accepted for publication March 17, 2008. * Address for reprints: Thierry Mesana, MD, PhD, University of Ottawa Heart Institute, 3402–40 Ruskin Street, Ottawa, Ontario, Canada, K1Y 4W7. (Email: tmesana{at}ottawaheart.ca).
Tricuspid regurgitation (TR) secondary to papillary muscle rupture is an uncommon surgical problem. We present 2 cases and offer an approach to surgical repair.
Case 1
An otherwise healthy 53-year-old man was referred to cardiac surgery for assessment of acute TR after a motor vehicle collision 6 months previously. Severe TR was noted on the patient's initial echocardiogram, but given his multiple injuries no attempt was made for immediate surgical repair. Progressive dilation of the right ventricle developed during the following several months, and repeat echocardiography revealed progressive dilation of his right ventricle. The patient was therefore brought to the operating room for elective tricuspid valve repair.
In the operating room, the patient was found to have an isolated flail of the anterior tricuspid leaflet secondary to ruptured chordae (
Figure 1, A). The tricuspid valve was repaired with a combination of bicuspidization (Figure 1, B), edge-to-edge repair (Figure 1, C), and ring annuloplasty (Figure 1, D). Intraoperative echocardiography revealed a post-repair orifice area of 2.6 cm2.
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Case 2
A 60-year-old man with known coronary artery disease presented to cardiac surgery with a 6-month history of progressive dyspnea. Echocardiography confirmed severe TR with bileaflet flail and moderate right ventricle dilation. The patient was brought to the operating room for tricuspid valve repair and concomitant coronary artery bypass grafting.
In the operating room, the anterior and posterior tricuspid leaflets were found to be torn from their respective papillary muscles (
Figure 2, A). The posterior leaflet was resected, and the septal leaflet chordae were transferred to the posteromedial aspect of the anterior leaflet with interrupted 5-0 Prolene suture (Figure 2, B). The annulus was then reconstructed by plicating the resultant defect, caused by resection of the posterior leaflet, with pledgeted 3-0 Prolene suture and interrupted 5-0 Prolene suture (Figure 2, C and D). The annulus was then measured at 28 mm with a Hegar sizer; therefore, no annuloplasty ring was implanted. The patient also received concomitant coronary bypass grafting. Post-repair echocardiography revealed a tricuspid orifice area of 2.8 cm2.
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Although described in the pediatric population and in patients after blunt trauma, severe TR secondary to ruptured chordae remains a rare and complex surgical problem.1,2 On the basis of the above cases, we propose 2 options for surgical TR repair.
The mechanism of TR in case 1 was the result of torn chordae from the anterior papillary muscle, thereby causing flail of the anterior leaflet. The posterior and septal leaflets, in addition to their respective chords and papillary muscles, were normal. The flail anterior leaflet could therefore be supported to the normal septal leaflet via an edge-to-edge repair (Figure 1, C) after bicuspidization (Figure 1, B). An annuloplasty ring was implanted to provide structural support because this patient was noted to have right ventricular dilation (Figure 1, D).
In case 2, anterior and posterior tricuspid leaflets were flail secondary to torn chordae and totally unsupported (Figure 2, A). An edge-to-edge repair was not feasible in this scenario given that there remained no normal chordae from either prolapsing leaflet to provide structural support. The septal leaflet, however, was found to have proper functioning chordae tendineae. Therefore, after posterior leaflet resection, the septal chords were transferred medially to the anterior leaflet (Figure 2, B).
Few reports have described the surgical management of TR caused by torn chordae tendineae. In the setting of isolated traumatic papillary muscle rupture, the edge-to-edge technique has been described as a means of supporting a flail tricuspid leaflet.3 Neochordae and papillary muscle reinsertion have also been described.4
However, an edge-to-edge technique may be insufficient in the setting of bileaflet or trileaflet flail. In such situation, the flip-over technique involved the portion of the septal leaflet adjacent to the posterior-septal commissure without jeopardizing atrioventricular node function. The flip-over with a lateral transfer toward the medial section of the anterior leaflet was achieved easily and without tension. This technique could also be applied to a more posterior segment of the anterior leaflet. To our knowledge, the surgical repair of bileaflet flail of the tricuspid valve has not been described. Common techniques for mitral valve repair, such as flip-over and edge-to-edge, are similarly applicable and successful in tricuspid valve repair as an alternative to tricuspid valve replacement.
References
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