Redo Tricuspid Valve Re-Replacement: Annular-Preserving Technique in a High-Risk Patient

Redo tricuspid valve replacement (TVR) is a technically demanding and high-risk surgical procedure, especially in patients with prior cardiac operations and multiple comorbidities. This case report outlines the use of an annular-preserving explantation technique utilizing electrocautery to safely remove a degenerated bioprosthetic tricuspid valve. The report emphasizes surgical planning, intraoperative management, and the patient’s postoperative course, contributing to the limited but growing body of literature on redo TVR. 

Patient Background 

The authors present the case of a 57-year-old male with an extensive medical history that included intravenous drug use (IVDU)-related infective endocarditis. He initially underwent a tricuspid valve replacement with a tissue valve in 2012 and required a permanent pacemaker implantation due to third-degree heart block. In the years that followed, he experienced recurrent Pseudomonas endocarditis. Additional comorbidities included chronic obstructive pulmonary disease (COPD), compensated cirrhosis, treated hepatitis C, gastroesophageal reflux disease (GERD), chronic tobacco use, methadone maintenance therapy, and two right posterior cerebral artery strokes with evidence of a right internal carotid artery thrombus. 

Preoperative Assessment 

Preoperative transthoracic echocardiography revealed severe degeneration of the existing 31 mm Mosaic porcine bioprosthesis, with both severe tricuspid regurgitation and moderate stenosis. Right heart catheterization demonstrated preserved right ventricular function, which was critical for considering reoperation. The TRI-SCORE was calculated at 6/12. Preoperative CT imaging revealed minimal retrosternal space, highlighting the potential hazard of reentry. Given the high-risk nature of the case, the multidisciplinary heart team reached a consensus to proceed with surgery. 

Operative Planning and Surgical Procedure 

The surgical strategy involved a redo sternotomy with preemptive right femoral artery and vein exposure to facilitate emergent cardiopulmonary bypass if needed. After careful reentry and lysis of dense adhesions, standard aortic and bicaval cannulation were performed, followed by the administration of antegrade cardioplegia. 

A right atriotomy was performed to expose the degenerated bioprosthesis. Electrocautery in cut mode at 40 watts was primarily used to explant the valve while preserving the annular structure. Intermittent use of a fine surgical blade allowed for precise dissection, with the prosthetic valve stabilized using a Kocher clamp. All previously implanted Teflon pledgets were retrieved to prevent potential embolization into the right ventricle. 
The right atrium and ventricle were thoroughly irrigated with saline. A new 31 mm Mosaic porcine valve was implanted using pledgeted Ethibond sutures from the atrial to the ventricular side. Intraoperative transesophageal echocardiography confirmed excellent prosthetic seating with no paravalvular leak and a mean transvalvular gradient of 1–2 mmHg. The preexisting pacemaker leads remained intact and functional. 

Postoperative Course 

The patient was weaned from cardiopulmonary bypass without difficulty. Right ventricular function remained mildly impaired but stable compared to baseline. Only minimal inotropic support was required, and the patient was extubated early with a smooth postoperative recovery. He was discharged home on postoperative day four. 

Discussion 

Redo TVR remains a high-risk operation associated with increased perioperative morbidity and mortality. Studies have reported a 10-year survival rate of approximately 50 percent after the initial tricuspid valve replacement (1) and highlight the challenges of reoperative cases, including elevated risk and surgical complexity (2). Right ventricular function is a key determinant of surgical risk and long-term outcomes. In reoperative cases, minimizing additional trauma by preserving the annulus can be crucial for improving surgical results. 
This case illustrates the effectiveness of an annular-preserving explantation technique using electrocautery, complemented by meticulous pledget removal and thorough saline irrigation. These steps allowed for safe valve replacement while minimizing operative trauma and preserving the right heart anatomy. 

Given the scarcity of high-quality intraoperative documentation in redo tricuspid interventions, this case contributes meaningful educational value to the cardiac surgical community. It demonstrates that with deliberate planning, disciplined techniques, and thoughtful patient selection, favorable outcomes can be achieved in even the most challenging surgical scenarios. 

Conclusion 

The authors successfully performed a redo tricuspid valve re-replacement in a high-risk patient using an annular-preserving technique supported by electrocautery. The procedure highlights the importance of careful preoperative planning, multidisciplinary collaboration, and meticulous surgical technique in optimizing outcomes for complex reoperative tricuspid valve cases. 

References

1. Filsoufi F, Anyanwu AC, Salzberg SP, Frankel T, Cohn LH, Adams DH. Long-term outcomes of tricuspid valve replacement in the current era. Ann Thorac Surg. 2005;80(3):845-850. doi:10.1016/j.athoracsur.2004.12.019
2. Bernal JM, Morales D, Revuelta C, Llorca J, Gutiérrez-Morlote J. The risk and outcomes of reoperative tricuspid valve surgery. Ann Thorac Surg. 2012;93(5):1641-1647. doi:10.1016/j.athoracsur.2012.01.051

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