Endoscopic Redo Tricuspid Valve Replacement After CABG

Redo tricuspid valve surgery after previous cardiac operations remains technically challenging and is associated with increased operative risk, particularly in elderly patients with extensive vascular calcifications and prior device-related complications. Minimally invasive and endoscopic approaches may reduce surgical trauma while maintaining procedural safety and effectiveness.

Case Presentation

This case demonstrates a 78-year-old male with previous coronary artery bypass grafting (CABG) ×3 (2022), who subsequently developed sick sinus syndrome requiring DDDR pacemaker implantation in 2025. Following pacemaker lead infection and right ventricular lead extraction, the patient developed massive tricuspid regurgitation caused by septal leaflet flail. A cardiac resynchronization therapy pacemaker (CRT-P) system with a coronary sinus lead was later implanted. Preoperative assessment demonstrated a TRI-SCORE of 2/12, with a predicted in-hospital mortality of three percent. Transthoracic echocardiography revealed a dilated tricuspid annulus measuring 40 mm, massive tricuspid regurgitation with a vena contracta of 10 mm, mild right ventricular dilation, mild-to-moderate mitral regurgitation, and preserved left ventricular systolic function. Computed tomography showed severe calcification of the aorta and iliac arteries, which significantly influenced operative planning.

Surgical Technique

The procedure was performed through a right minithoracotomy in the fourth or fifth intercostal space under bilateral lung ventilation. Due to the heavily calcified descending aorta, direct axillary artery cannulation was selected for cardiopulmonary bypass, while venous drainage was achieved through percutaneous femoral vein cannulation using the Seldinger technique with a multistage venous cannula and vacuum-assisted drainage. A jugular venous wire for temporary pacing was positioned preoperatively. Endoscopic visualization was obtained through a camera port in the fourth intercostal space.

A beating-heart endoscopic tricuspid valve replacement was performed using a bioprosthetic valve in combination with a 5 mm RAM device and the Cor-Knot system. Following a horizontal pericardial-right atrial incision, exposure of the tricuspid valve was achieved using a left atrial retractor and multiple free-wall traction sutures externalized with a snare system. Annular sutures were placed using the 5 mm RAM device. Additional aortic root compression optimized valve exposure and ensured perpendicular alignment to the endoscopic camera. The prosthesis was implanted with the aortic side oriented toward the septal leaflet, and fixation was completed using the Cor-Knot system. The right atriotomy was closed with a continuous 4-0 polypropylene suture.

Results

The total operative time was three hours, with a cardiopulmonary bypass time of 114 minutes. Postoperative echocardiography demonstrated optimal prosthetic valve function without residual regurgitation. The patient was extubated on the day of surgery in the intensive care unit, transferred to the surgical ward on postoperative day two, and discharged home on postoperative day five.

Conclusion

Beating-heart endoscopic tricuspid valve replacement using a 5 mm RAM device represents a feasible and effective minimally invasive option for high-risk redo patients after CABG and device-related tricuspid valve injury. Careful preoperative imaging, a tailored cannulation strategy, and enhanced endoscopic exposure techniques can facilitate safe valve implantation and favorable early postoperative recovery.

References

1. Cardiothoracic Surgery Lu S, Song K, Yao W, et al. Simplified, minimally invasive, beating-heart technique for redo isolated tricuspid valve surgery. Journal of Cardiothoracic Surgery. 2020;15:146. doi:10.1186/s13019-020-01192-1.
2. Cardiothoracic Surgery Färber G, Tkebuchava S, Dawson RS, et al. Minimally Invasive, Isolated Tricuspid Valve Redo Surgery: A Safety and Outcome Analysis. Thoracic and Cardiovascular Surgeon. 2018;66(7):564-571. doi:10.1055/s-0038-1627452.
3. Cardiothoracic Surgery Misfeld M, Davierwala P, Banusch J, et al. Minimally invasive, beating heart tricuspid valve surgery in a redo case. Annals of Cardiothoracic Surgery. 2017;6(3):290-293. doi:10.21037/acs.2017.05.10.

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