Matthew Janko MD and Joseph Sabik III MD
Case Western Reserve University, Cleveland, OH, USA
Essential Operative Steps
- Preoperative transesophageal echocardiographic assessment of the target valve
- Lines and monitoring
- General endotracheal anesthesia
- Intraoperative TEE
- Median sternotomy
- Systemic heparinization (400 u/kg)
- Check ACT (>480 sec)
- Ascending aorta and bicaval cannulation for CPB
- Right atriotomy and direct visual assessment of the tricuspid valve
- Identification of tricuspid leaflet pathology, leaflet excision, and plication of the tricuspid annulus
- Creation of a new commissure by sewing the remaining leaflets together
- Test the tricuspid valve for competence
- Wean from CPB
- Assessment of valvular function by TEE
- Tricuspid valve replacement, if necessary
- Protamine administration for heparin reversal
- Aortic and venous decannulation
- Assess hemostasis
- Chest tube placement
- Sternotomy closure
Potential Complications and Pitfalls
- Injury to the conducting system by touching or stitching through the triangle of Koch
- Valve dysfunction at case completion: remember, valve replacement is a bailout
- Ensure endocarditis is sufficiently excised and there is no remaining infectious material upon completion of the
leaflet excision
Template Dictation
Preoperative Diagnosis: Symptomatic tricuspid valve regurgitation due to endocarditis
Postoperative Diagnosis: Same (with appropriate adjustments)
Procedure(s) Performed: Tricuspid valve repair with on-pump beating heart
Attending Surgeon: [BLANK]
Secondary Surgeon: [BLANK]
Assistants: [BLANK]
Anesthesia: [BLANK]
Indications for Procedure: This is a [AGE] [SEX] patient who developed tricuspid valve endocarditis and was
previously treated with antibiotics. They developed heart failure and echocardiography demonstrated severe tricuspid
insufficiency with [FINDINGS].
Description of the Procedure: The patient was taken to the operating room on [DATE] and placed upon the operating
table in the supine position. A safety pause was performed in the presence of the entire operating room team including
the attending surgeon, attending anesthesiologist, nurses, and perfusionists. The patient’s identity and operative plan
were confirmed with the entire operating room staff. General anesthesia was induced, and a brachial artery line was
inserted. Preoperative TEE was performed. The patient was prepped and draped in the usual sterile fashion.
A median sternotomy was performed. The thymus was divided, and the pericardium was opened. There were no
pericardial adhesions or effusions. The ascending aorta was palpated, and it was soft without evidence of atherosclerosis.
The right atrium and right ventricle were noted to be enlarged. Unfractionated heparin sulfate was administered
intravenously, and the activated clotting time was noted to be greater than 480 seconds. The ascending aorta was
cannulated and the IVC and SVC were individually cannulated. CPB was initiated and silastic bands were placed around
the IVC and SVC cannulas.
A right atriotomy was performed and retractors were placed, exposing the tricuspid valve. The anterior and septal leaflets
of the tricuspid valve appeared normal. The posterior leaflet had a chronic calcified vegetation on it and much of this
leaflet was destroyed. The remnants of the posterior leaflet along with the chronic calcified vegetation were excised.
The tricuspid valve annulus in this area was reduced with a pledgeted 2-0 non-absorbable braided polyester suture. We
then created a new commissure between the anterior and septal leaflets by sewing the leaflets together with 2 layers of
running 5-0 polypropylene. The valve was then tested, and it appeared to be competent. The retractors were removed
and the right atriotomy was closed with two layers of running 5-0 polypropylene. The right atrium was deaired during
closure. The patient was then weaned from CPB without difficulty. A [TYPE: spontaneous sinus or other] rhythm was
observed.
[RESULT #1: Intraoperative transesophageal echocardiography demonstrated similarly normal ventricular function
and a well-functioning repaired tricuspid valve with no tricuspid regurgitation]. [RESULT #2: Intraoperative
transesophageal echocardiography was concerning for persistent valvular dysfunction and incompetence. Thus, the right
atrium was re-entered through the prior incision, and we proceeded with tricuspid valve replacement. The prior annular
plication stitches were removed, and the valve was measured using the manufacturer’s sizing rings. Interrupted
pledgeted 2-0 non-absorbable braided polyester sutures were placed around the tricuspid valve annulus, being careful
to completely avoid Koch’s triangle, the atrioventricular node, and the conducting system. Annular stitches were then
placed through the sewing skirt cushion of the replacement valve and the valve was lowered into position. Knots were
tied with an automated device. The valve was tested with saline, and the result was satisfactory. The right atrium was
closed in two layers and cardiopulmonary bypass was weaned. Intraoperative TEE demonstrated similarly normal
ventricular function and a well-functioning tricuspid valve replacement with no regurgitation].
All cannulas were removed, and the heparin effect was reversed with protamine. Hemostasis was obtained. Chest tubes,
including mediastinal and right pleural chest tubes, were placed. The wounds were closed in the standard fashion. The
specimen included the chronic calcified vegetation and remnants of the posterior leaflet. The specimen was sent to
pathology. The estimated blood loss was [BLANK]cc.
All instrument, sponge, and needle counts were confirmed to be correct, twice, at the end of the surgical procedure. The
patient was subsequently transferred to the postoperative cardiac surgical intensive care unit in stable condition.
Dr. [BLANK] was present and scrubbed for [BLANK] elements of the procedure.
Multiple Choice Question(s)
Which of the following is true?
A. Tricuspid regurgitation is common in patients with chronic heart failure, and its incidence is increasing,
particularly among older patients with transtricuspid leads, right ventricular dysfunction, or previous left-sided
valve surgery
B. Concomitant surgical repair of mild or moderate tricuspid regurgitation at the time of surgical repair of
degenerative mitral valve regurgitation has been shown to be associated with lower risk of progression to severe
tricuspid regurgitation and higher risk of permanent pacemaker insertion
C. Bicuspidization of the tricuspid valve results in approximately 75% freedom from moderate or severe tricuspid
regurgitation at 3 years
D. Surgery for endocarditis should generally be approached via median sternotomy
E. All of the above
Answer: E.
Sources
Asmarats L, Taramasso M, and Rodés-CabauJ. Tricuspid valve disease: diagnosis, prognosis, and management of a
rapidly evolving field. Nat Rev Cardiol 2019; 16:538–554.
Tchantchaleishvili V, Taufiek K. RajabTK, Cohn LH. Posterior suture annuloplasty for functional tricuspid
regurgitation. Annals of Cardiothoracic Surgery 2017; 6.
Gammie JS, Chu MWA, Volkmar F, et al. Concomitant Tricuspid Repair in Patients with Degenerative Mitral
Regurgitation. NEJM 2022; 386:327-339.
