Cone Repair for Tricuspid Valve Endocarditis

The classic cone repair was defined by Da Silva based on the Carpentier experience for tricuspid valve repair in Ebstein anomaly (1). This operation mainly consists of separating the tricuspid valve leaflets from the annulus, proximal displacement, and rotation of the leaflets to cover the entire new annular area when the septal leaflet is absent or has severe apical displacement. This video demonstrates how the cone repair can be applied to other situations where the septal leaflet is absent or malfunctioning, such as destruction by endocarditis.

The patient is a thirty-five-year-old male IV drug abuser with severe tricuspid valve endocarditis causing severe regurgitation. He was febrile and was in frank heart failure. The decision for surgery was made after two weeks of antibiotic therapy and the operation was performed to repair or replace the tricuspid valve. The primary operative finding was that the septal leaflet was severely destroyed with large, bulky vegetations. The anterior and posterior leaflets were not affected. The tricuspid annulus was dilated to 38-40 mm. 

To begin, the septal leaflet was removed and debridement was performed, leaving a bare area 3 cm long at the septal annulus. The main options for repairing the valve were to replace the septal leaflet with artificial or biologic materials and patches supported by artificial chords. However, surgeons preferred to do the repair entirely by the autologous tricuspid valve tissue using the cone technique.

The remaining tricuspid leaflets, including the anterior and posterior cusps, were separated from their atrioventricular basal attachment by leaving the annular tissue on the leaflet side. This was because the leaflet tissue at the basal area was extremely thin, and cutting and suturing could result in either immediate or late tearing and dehiscence. The authors have previously provided a comprehensive explanation of this technique in a previous video on CTSNet (2).

Next, the detached leaflets then rotated clockwise to cover the entire annular circle and reattached to the annulus. Some tethering of the leaflet at the anteroseptal commissure was managed by connecting the tethered part to the adjacent cusp and cutting the tethering chords. A 30 mm annuloplasty ring was used to stabilize the repair. There was no tricuspid stenosis or tricuspid regurgitation on the TEE after coming off bypass. The patient received six weeks of antibiotics after the operation and is completely stable six months later.

To summarize, the essence of the cone repair can be utilized for tricuspid valve repair in conditions that are not associated with Ebstein anomaly, where the septal and/or the posterior leaflets are defective and nonfunctional.

References

1. da Silva, J. P., Baumgratz, J. F., da Fonseca, L., Franchi, S. M., Lopes, L. M., Tavares, G. M. P., … & Barbero-Marcial, M. (2007). The cone reconstruction of the tricuspid valve in Ebstein’s anomaly. The operation: early and midterm results. The Journal of Thoracic and Cardiovascular Surgery, 133(1), 215-223.
2. A.A.Amirghofran, Tricuspid Valve Patch Augmentation with Annular Detachment in Thin Leaflet Valves. https://www.ctsnet.org/article/tricuspid-valve-patch-augmentation-annula…

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