Excision of Obstructing Right Ventricular Mass and Tricuspid Valve Replacement

THank you Dr.Arie for this nice case, I had faced the same large RV mass in a 55 yrs female one month ago.The mass involved most of RV space and even compressed the septum and also caused severe TVR . The patient had a history of left kidney excision due to Clear cell carcinoma 2 years ago .The heart mass was a metastasis which was the only detected metastasis of this CA. Thanks again

Thank you, Firas. These are unusual cases, and it would be great to compile a series to discuss the surgical alternatives. Because of my patient's youth, he remained well compensated until his presentation. Cheers.

Really nice video and nice job Dr Arie. Which valve do you generally use in tricuspid position? Do you think that porcine valves (with thinner leaflet) perfom better than pericardial valve with thicker leaflets in a low pressure chambers system? Thanks

Hi Gianluca, thank you for your comment. I generally use porcine tissue valves for all locations in the heart, but I have never thought of the thickness of the leaflets as being an important discriminator on the right side. I am very happy with the long-term durability of the Mosaic valves, and I appreciate the flexibility and safety provided by the cinching mechanism. I do think your question is very provocative, however--are you aware of any data to suggest the thickness of the leaflets is important here?

Very informative video of a very strange pathology. I have two questions- 1. Was there any evidence of hypercoagulable disorder?- I have seen an odd LV thrombus in a patient with Factor V Leiden. 2. I am a bit puzzled by the somewhat delayed appearance of RV dysfunction- was there any element of RCA ischemia?

Once the acute postoperative state subsided, the patient's coagulation profile was thoroughly evaluated and no hypercoagulability was discovered. His presentation is a mystery on multiple levels. First, the patient had very few risk factors for DVT--i.e., he is young and active. Second, the degree of RV dysfunction, both preoperatively and postoperatively, was beyond what might be expected. He did have gross enlargement of the TV and RV, presumably compensatory to allow maintenance of his cardiac output in the presence of TV and RV obstruction. His presentation was that of decompensated HF, as his RV function reached a critical threshold of inadequacy. Thanks for your questions.

very very nice,,,,,the most wonderful thing is the sinus rythm

thank you sir....i would like to ask you one question....if the anatomy was so complex that replacement of the tcv is impossible..would this patient have tolerated without valve????

Alwaleed, Thank you for your question. In my opinion, it is doubtful that the patient would have tolerated excision of the mass without a tricuspid valve replacement due to the degree of underlying RV dysfunction. If the patient was moribund at the time of surgery but had good RV function, I think excision alone is a worthwhile consideration in such a selected case.