58. Tricuspid Valve Replacement

Abhishek K. Kashyap, MD and David G. Rabkin, MD
Loma Linda University Medical Center, Loma Linda, CA, USA

Essential Operative Steps

  1. Lines and monitoring
  2. General endotracheal anesthesia
  3. Intraoperative transesophageal echocardiogram
  4. Median sternotomy
  5. Systemic heparinization
  6. Arterial cannulation
  7. SVC cannulation
  8. IVC cannulation
  9. Placement of caval snares
  10. Placement of aortic root vent
  11. Check ACT
  12. Initiate CPB
    a. Optional: Aortic crossclamp
    b. Optional: Antegrade cardioplegia and topical cooling
  13. Stay sutures on right atrium
  14. Right atriotomy
  15. Assess tricuspid valve to determine suitability of repair (normal leaflets and chordal structures with a dilated annulus is
    usually repairable; significant anterior or posterior leaflet pathology without a dilated annulus often requires
    replacement)
  16. Excise tricuspid valve leaflets
  17. Choose prosthetic valve and size (measure intertrigonal distance)
  18. Place annular sutures
  19. Implant valve
  20. Test valve
  21. Close atriotomy
  22. Antegrade “Hot Shot”
  23. Remove crossclamp
  24. Check for hemostasis
  25. Temporary epicardial pacer wire placement
  26. Wean from bypass
  27. Administer protamine
  28. Place mediastinal tubes
  29. Close sternotomy

Potential Complications and Pitfalls

  1. Deviation from midline during sternotomy
  2. Cannulation complication such as aortic dissection/disruption, inadequate anticoagulation
  3. Insufficient myocardial protection
  4. Inadequate annular debridement of infected or devitalized tissue
  5. Poor seating of valve
  6. Injury to AV node or bundle of His
    a. Can avoid this in two ways: 1) can do the procedure without arresting the heart thereby recognizing injury to
    conduction system immediately and removing the culprit suture or 2) can place valve sutures through the base of
    the septal leaflet in the region of the conduction system – triangle of Koch
    b. Consider placement of permanent epicardial leads in patients who are at high risk for needing a permanent
    pacemaker in the future. Patients with existing pacemaker leads can have the right ventricular lead positioned
    between the sewing ring and the annulus to prevent damage to the prosthetic valve leaflets
  7. Damage to prosthetic valve (commissure posts, leaflets) during suture tying
  8. Paravalvular leak
  9. Inadequate control of hemostasis prior to sternal closure
  10. Postoperative RV failure
    a. Important to get right heart catheterization preoperatively to assess pulmonary vascular resistance and rule out fixed
    pulmonary hypertension prior to valve replacement
    b. Overall high-risk operation, with 13% mortality and 50% ten-year survival (series from Wash U: Moraca RJ, Moon
    MR, Lawton JS, Guthrie TJ, Aubchon KA, Moazami N, Pasque MK, Damiano RJ Jr. Ann ThoracSurg
    2009;87(1):83.)
  11. Long term valve thrombosis
    a. Bioprostheses are preferred, despite finite durability, due to the propensity for thrombus formation on mechanical
    prostheses in the tricuspid position

Template Dictation
Preoperative Diagnosis: [INDICATION: Dyspnea on exertion, exertional syncope, ascites, hepatomegaly/splenomegaly,
peripheral edema, right heart failure, severe tricuspid regurgitation, severe tricuspid stenosis]
Postoperative Diagnosis: Same (with appropriate adjustments)
Procedure Performed: Tricuspid valve replacement with [PROSTHETIC VALVE INFORMATION]
Attending Surgeon: [BLANK]
Secondary Surgeon: [BLANK]
Assistants: [BLANK]
Anesthesia: [BLANK]


Indication(s) for Procedure: [AGE] year old [SEX] with [DURATION] history of [COMPLAINT: dyspnea on exertion,
exertional syncope, ascites, hepatomegaly/splenomegaly, peripheral edema, right heart failure, severe tricuspid regurgitation,
and/or severe tricuspid stenosis]. Preoperative cardiac echocardiography demonstrated [FINDINGS]. The tricuspid valve was
not thought to be repairable due to [FINDINGS].


Description of the Procedure: The patient was brought to the operating room and laid supine on the operating room table.
Appropriate lines were placed, and monitors were connected by the anesthesia team. General anesthesia was induced. A
multidisciplinary preoperative timeout was then completed, and all parties agreed. An intraoperative TEE was then performed
which confirmed the pathology. Pressure points were padded. The patient was then prepped and draped in the usual sterile
fashion.


A conventional median sternotomy was used to open the chest. The sternum was [unremarkable or osteoporotic]. The patient
was systemically heparinized (300 u/kg) with a target ACT >480. The pericardium was opened, and pericardial stay sutures
were placed. After manual palpation to confirm the absence of aortic atherosclerosis, pursestring sutures were placed in the
aorta, superior vena cava, and inferior vena cava. The aorta was cannulated with a [CANNULA TYPE]. The aortic cannula
was carefully deaired and secured to the arterial limb of the bypass circuit. The superior vena cava was cannulated with a
[CANNULA TYPE] and the inferior vena cava was cannulated with a [CANNULA TYPE]. [ALTERNATIVELY: The left
femoral vein was accessed percutaneously, and a wire was passed up to the right atrium. After sequential dilation, a
[CANNULA TYPE] cannula was placed into the IVC and secured]. Both the superior and inferior vena cava were encircled
with umbilical tapes. An antegrade cardioloplegia cannula was placed and also served as an aortic root vent. Cardiopulmonary
bypass was initiated and there were excellent pressures, flows, and venous oxygenation for the duration of the case. The patient
was cooled to [TEMPERATURE]oC. Both cava were snared. [OPTIONAL: The heart was arrested after the crossclamp was
placed, during a transient moment of low flow on the pump, using cold blood cardioplegia. There was excellent
electromechanical arrest for the duration of the case. Interval doses of cardioplegia were given every fifteen to twenty minutes].
Two silk stay sutures were placed on the right atrium. The right atrium was then opened with an oblique incision. Atrial
retractors were placed, and the tricuspid valve was then inspected revealing [DETAILS ABOUT TRICUSPID
PATHOLOGY: fenestrations, vegetations, calcification, etc]. The anterior and posterior tricuspid valve leaflets were then
excised leaving a 2-3mm rim of leaflet tissue and the septal leaflet was left in situ. [ALTERNATIVELY: The septal leaflet
was completely excised leaving a 2-3mm rim of leaflet tissue]. The tricuspid annulus was sharply debrided of non-vital tissue.
The right ventricle was copiously irrigated with saline. The annulus was sized by measuring the intertrigonal distance. A
[IMPLANT SIZE]mm [IMPLANT TYPE] valve was selected and washed. Pledgeted 2-0 ethibond sutures were then placed
circumferentially around the tricuspid valve annulus with pledgets oriented on the atrial side. The sutures were passed through
the sewing ring, the valve was lowered into position, and the sutures were tied securely into place. The valve was found to be
well seated, and leaflets were tested and found to function normally. The right atriotomy was then closed with a double layer
of 5-0 prolene suture.


A dose of warm blood cardioplegia was then given and the patient was placed in the head down position. During a brief period
of low flow, the crossclamp was removed. The heart was reanimated in [RHYTHM]. Temporary pacing wires were placed on
the surface of the [LOCATION: right atrium, right ventricle]. The suture line was inspected and found to be hemostatic. The
patient was ventilated. When the patient was fully rewarmed with good cardiac rhythm and contractility, the patient was weaned
from CPB on [INOTROPES OR PRESSORS]. TEE confirmed a well seated valve with no paravalvular leak and an
acceptable gradient. The venous cannulae were removed. The aortic root vent was removed after confirming the heart was void
of air on transesophageal echocardiography. Protamine was administered. The pump volume was returned to the patient via
the aortic cannula. The aortic cannula was removed. All surgical and cannulation sites were inspected for hemostasis and
repaired as necessary. Topical hemostatic agents were used as necessary. Mediastinal chest tubes were placed and secured. The
incision was then closed in layers with #5 stainless steel wires used to approximate the sternum, 0 vicryl suture used to
approximate the fascia, 3-0 vicryl to approximate the subcutaneous tissue, and 4-0 monocryl subcuticular closure used to

approximate the skin. Sterile dressings were applied. The patient tolerated the procedure well and was transferred to the ICU
in stable condition.


All sponge, instrument, and needle counts were correct at the completion of the case.


Dr. [BLANK] was present and scrubbed for [BLANK] elements of the procedure.


Figure 1: (A) Right atriotomy with SVC and IVC cannulated with visualization of non-repairable fenestrated posterior
tricuspid valve leaflet. (C) Sutures are passed through prosthetic valve with (D) annular sutures in place and (E) a seated and
secured bioprosthetic tricuspid valve.

Multiple Choice Question(s)

1. What is the operative mortality for isolated TVR in the United States?

A. <1%

B. 3%

C. 5%

D. 7%

E. ≥9%

Answer: E.

2. What is the best strategy for management of a permanent RV lead?

A. Replace it with permanent epicardial lead

B. Secure the lead in a commissure

C. Imbricate the lead between the sewing ring and the annulus

D. All of the above

Answer: D. All are reasonable strategies.

3. All of the following are acceptable management options of an IV drug user with native TV endocarditis EXCEPT:

A. Engagement of multidisciplinary team (Infectious Disease, Case Management, Drug counselors, etc)

B. Tricuspid valve repair, if possible

C. Tricuspid valve replacement if repair is not possible

D. Excision of the native tricuspid valve only

E. Medical management

Answer: D. Not universally considered an acceptable management for all comers as some ethical implications exist here. Although can be considered in rare circumstances in risk prohibitive with recidivism.

  1. Which of these patients is a good candidate for tricuspid valve replacement?
    A. 55-year-old with longstanding severe TR from secundum ASD, bidirectional shunt at the atrial level and significant RV
    dysfunction
    B. Recidivist injection drug user with prosthetic valve endocarditis
    C. 65-year-old with infected RV pacing lead leading to damaged TV leaflets and severe TR
    D. 60-year-old with severe TR, an annulus measuring 42mm, and normal leaflets
    Answer: C. The first patient likely has fixed pulmonary hypertension and will decompensate after TVR. The second patient
    has a high likelihood of reinfecting the valve (may undergo replacement, but not a ‘good candidate). The last patient should
    have a tricuspid repair.

Sources
Zack CJ, Fender EA, Chandrashekar P et al. National trends and outcomes in isolated tricuspid valve surgery. JACC
2017;70(24):2953.
(2020 ACC/AHA Guideline for the management of patients with valvular heart disease. Otto et al. Circulation 2021)
Moraca RJ, Moon MR, Lawton JS, Guthrie TJ, Aubchon KA, Moazami N, Pasque MK, Damiano RJ Jr. Ann ThoracSurg
2009;87(1):83

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