Benjamin Yang, MD and Haytham Elgharably, MD
Cleveland Clinic, Cleveland, OH, USA
This chapter is a revision and update of that included in the previous edition of the TSRA Operative Dictations in
Cardiothoracic Surgery written by Mathéau A. Julien, MD, PhD and Duc Thinh Pham, MD.
Essential Operative Steps
- Lines and monitoring. If Swan-Ganz is indicated (such as for right ventricular dysfunction or pulmonary hypertension),
don’t pass through a tricuspid valve with large mobile vegetations to avoid embolization. It can be passed directly by the
surgeon after finishing the procedure and before closing the right atrium - General anesthesia with single lumen endotracheal tube
- Intraoperative TEE, check for the presence of PFO with the anesthesiologist using agitated saline test
- Median sternotomy
- Open the pericardium toward the right side, leaving enough size of intact pericardium for possible patch repair of the
tricuspid valve - Survey ascending aorta for plaque burden
- Systemic heparinization (400 u/kg)
- Aortic cannulation
- Bicaval cannulation
- Check ACT (>400 seconds)
- Initiate CPB
- Application of caval snares (SVC and IVC)
- Placement of antegrade cardioplegia cannula in the aortic root
- Aortic crossclamp (reduce CPB flow rate, apply crossclamp, increase CPB flow to 2.0-2.5L/min/m2)
- Give antegrade cardioplegia and topical cooling for cardiac arrest
- Perform right atriotomy
- Consider placement of direct retrograde cardioplegia cannula in the coronary sinus in cases of ventricular dysfunction for
optimal myocardial protection - Close PFO if present
- Careful inspection of the tricuspid valve annulus, leaflets and subvalvular apparatus for extent of endocarditis
- Radical debridement of all infected tissues with attached vegetations and any surrounding necrotic tissue. Send samples
for microbiology and pathology examination - Copious irrigation of right ventricle and tricuspid valve
- Examine the remaining healthy leaflet tissue to determine repairability, and if so, plan the approach of repair
- Placement of annuloplasty stitches to aid with exposure of the valve
- Use intact chordal attachment to the leaflet tissue to determine the size of autologous pericardium required to reconstruct
the leaflet defect - Anchor pericardial patch to edges of leaflet defect, attach using running suture (e.g. 6-0 prolene). Alternatively, annular
plication can be used if damage is confined to the posterior leaflet - In case of damaged chordae, neochords can be used to attach to the subvalvular apparatus by passing through the fibrous
top of the papillary muscle and then through the edge of the leaflet of the pericardial patch. The neochords are left untied - Appropriate sizing and subsequent placement of tricuspid annuloplasty band
- After insertion of the annuloplasty band, the height of the neochords is adjusted based on the coaptation level
- Tricuspid valve competence tested by distending the right ventricle using a bulb syringe. Neochord height adjusted then
tied - Antegrade warm blood cardioplegia “hot shot” administration
- Remove aortic crossclamp, deairing through aortic root vent especially if there was a PFO
- Closure of right atriotomy
- Remove caval snares, restart mechanical ventilation, then wean from CPB
- Check for hemostasis
- Temporary ventricular pacing wire placement on the RV surface
- Drainage chest tube placement
- Assess quality of repair with intraoperative TEE
- Venous and aortic decannulation
- Protamine administration for heparin reversal (test dose first)
- Assess hemostasis
- Sternotomy closure
Potential Complications and Pitfalls
- Residual infection. Complete resection of all infected tissue is necessary to obtain source control for endocarditis. In cases
where a quality repair is not attainable due to extent of valvular or subvalvular involvement, tricuspid valve replacement
is preferred - Injury to conduction system. Understanding of the tricuspid valve anatomy and surrounding structures is essential to
performing tricuspid valve annuloplasty. AV node and bundle of his are important structures contained in the Triangle of
Koch. Annuloplasty sutures that violate this space will cause significant conduction abnormalities. Transient
bradyarrhythmia can occur after tricuspid valve repair, if persistent, patients may need a permanent pacemaker. In addition
to temporary ventricular pacing wires, consider placing temporary atrial pacing wires in case of bradyarrhythmia after
surgery affecting hemodynamics requiring AV pacing - Severe aortic insufficiency coming off bypass. The right and noncoronary sinus leaflets of the aortic valve are close to
the anterior leaflet of the tricuspid valve toward the anteroseptal commissure. If encountered, resume CPB to perform
aortotomy and directly inspect aortic valve - Injury to the right coronary artery with deep sutures placed in the “danger zone” (anteroposterior commissure). Suspicion
is raised with new RV dysfunction, inferior LV wall motion abnormality, EKG changes, or refractory ventricular
arrhythmia upon separation from CPB. If suspicion is high, resume CPB and replace the sutures in the relevant area with
more superficial sutures. If the pathology is secondary to entrapment of the pericoronary tissue causing kinking of the
vessel, it could resolve after replacing the sutures. If pathology persists, consider bypass grafting of the right coronary
artery with a saphenous vein graft - Residual tricuspid regurgitation after repair. Carefully examine the mechanism of the residual tricuspid regurgitation with
the anesthesiologist on TEE. Can revise patch or revise length of neochords. Bulb syringe testing to assess for leaflet
coaptation prior to separation from bypass can give the surgeon a better idea of need for revision upfront - Patients with chronic tricuspid regurgitation secondary to endocarditis may develop right ventricular dilation and
dysfunction as well as pulmonary hypertension from recurrent septic emboli. Careful preparation with anesthesia and ICU
teams for perioperative management of right ventricular dysfunction is critical for these cases, including usage of
inotropes or pulmonary vasodilators - Resected tissue should be sent for pathology and culture to help guide antibiotic selection for treatment of endocarditis
Template Dictation
Preoperative Diagnosis: Tricuspid Valve Endocarditis
Postoperative Diagnosis: Same (with appropriate adjustments)
Procedure(s) Performed: Tricuspid Valve Repair with Annuloplasty
Attending Surgeon: [BLANK]
Secondary Surgeon: [BLANK]
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: [AGE] year old [SEX] with severe tricuspid regurgitation, large >2cm vegetation, and history
of recurrent pulmonary septic emboli who presented with persistent bacteremia despite treatment with appropriate antibiotics
for 7 days.
Description of the Procedure: After informed consent was obtained, the patient was brought to the operating room and placed
in the supine position. General anesthesia was induced. A central venous catheter, radial arterial catheter, and Foley catheter
were inserted. The patient was prepped and draped in the usual sterile manner. A median sternotomy was performed. The
pericardium was incised toward the right pleura in case a patch of pericardium was needed for reconstructive repair. The patient
was systemically heparinized. Double pursestring sutures were placed in the ascending aorta, and it was cannulated in the usual
fashion. The venous lines were prepared for SVC and IVC cannulation, and after placing single pursestring sutures, these were
cannulated as well, using right-angle cannulas. Once a therapeutic ACT was achieved the patient was placed on CPB and kept
warm. The SVC and IVC were each looped using vessel loops.
An aortic root vent / antegrade cardioplegia cannula was placed in the proximal ascending aorta. The aorta was crossclamped,
and cardioplegia given antegrade into the aortic root. After appropriate cardiac arrest was achieved, the superior and inferior
vena caval tapes were snared down. The operative field was flooded with carbon dioxide. The right atrium was then opened
through a horizontal atriotomy parallel to the atrioventricular groove. No atrial septal defect was identified. Attention was then
turned to the tricuspid valve. The valve leaflets were then inspected systematically, and a large vegetation was identified on
the [BLANK] leaflet. The lesion was resected, including any affected chordae. The specimen was divided and placed in sterile
containers for pathology and culture. The remaining subvalvular apparatus was inspected and copiously irrigated. The valve
appeared reparable. We started with placement of interrupted, non-pledgeted 2-0 ethibond annuloplasty stitches, starting from
the mid-septal leaflet in a counterclockwise fashion around the tricuspid annulus, to just proximal to the anteroseptal
commissure. We harvested an appropriate size autologous pericardial patch. This was then anchored to the edges and center of
the valvular defect using running 6-0 prolene suture. 5-0 Gore-Tex neochords were then passed through the fibrous part of the
papillary muscle and then through the free edge of the patch and left untied. Attention was turned to sizing the annuloplasty
band. Using the appropriate size, the annuloplasty sutures were secured to the annuloplasty band and tied down. We then
adjusted the height of the neochords based on the new coaptation level after placing the patch and the annuloplasty band. The
neochords were tied loosely with one knot. Next, the tricuspid valve competence was tested by distending the right ventricle
using saline. After adjusting the length of the neochords, utilizing saline testing to achieve best coaptation, the neochords were
tightened. The right atriotomy was then closed with a running 4-0 prolene suture in imbricating fashion.
The patient was successfully weaned off CPB. Intraoperative echocardiogram showed a competent repair with no tricuspid or
aortic insufficiency. The heart was deaired and decannulated. Heparin was reversed with protamine. Two temporary right
ventricular epicardial pacing wires were placed. The pericardial cavity was copiously irrigated, hemostasis was assured, and
two mediastinal drainage tubes were placed. The sternum was reapproximated with wires. The rectus and pectoralis fascia were
closed with 0 prolene. The subcutaneous tissue was closed with 2-0 prolene, and the skin was closed with 4-0 monocryl. All
wounds were sterilely dressed. Instrument and sponge counts were correct, twice. The patient tolerated the procedure well and
was sent to the critical care unit in stable condition.
Dr. [BLANK] was present and scrubbed for [BLANK] elements of this procedure.
Multiple Choice Question(s)
A 55-year-old male with a history of IV drug use is referred to you with MRSA endocarditis and septic emboli to the lungs.
Intraoperative TEE is significant for a 2.7 cm posterior leaflet vegetation with involvement into the subvalvular apparatus, no
PFO, mild LV dysfunction, and moderate RV dysfunction. Inspection of the valve revealed near complete destruction of the
three tricuspid valve leaflets, so you opt for a bioprosthetic valve replacement. While coming off of CPB, you notice that the
patient is in 3rd degree AV block. Which of the following would provide the best long-term solution for the patient?
A. Remove bioprosthetic valve and perform tricuspid valvulectomy
B. Remove bioprosthetic valve and replace with mechanical valve
C. Placement of permanent RA and RV epicardial leads tunnel to subcutaneous pocket
D. Temporary RV pacing lead placement only with transvenous pacemaker lead placement if bradyarrhythmia persists
E. Bypass RCA with vein graft and initiate inhaled epoprostenol
Answer: C.
Sources
Carpentier AF, Adams DH, Filsoufi F, Williams M. Carpentier’s reconstructive valve surgery: from valve analysis to valve
reconstruction. Maryland Heights, Mo: Saunders Elsevier; 2010.
Dawood MY, Cheema FH, Ghoreishi M, Foster NW, Villanueva RM, Salenger R, et al. Contemporary outcomes of
operations for tricuspid valve infective endocarditis. Ann Thorac Surg 2015;99:539–46..
Kay JH, Maselli-Campagna G, Tsuji KK. SURGICAL TREATMENT OF TRICUSPID INSUFFICIENCY. Ann Surg
1965;162:53–8.
Hussain ST, Witten J, Shrestha NK, Blackstone EH, Pettersson GB. Tricuspid valve endocarditis. Ann Cardiothorac Surg
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