Redo Tricuspid Valve Replacement Technique Under Right Heart Bypass for a Previously Repaired Tricuspid Valve

This video submission is from the 2025 CTSNet Innovation Video Competition. Watch all entries from the competition, including the winning videos.   

This video demonstrates the technique for conducting a redo tricuspid valve replacement under right heart bypass. Tricuspid valve replacement is associated with poor surgical outcomes compared to other valve replacement procedures, primarily due to accompanying right ventricular dysfunction in patients with tricuspid valve disease. The right ventricle's apex-to-base shortening diameter is displayed by the tricuspid annular plane systolic excursion (TAPSE), which is used to characterize its function. Patients with a TAPSE < 15 are known to be associated with worse outcomes.  

Conventional cardiopulmonary bypass (CPB) is associated with myocardial ischemia and systemic inflammatory response syndrome (SIRS). Hence, performing tricuspid valve surgery on a beating heart has become popular (1).  

Redo surgery is also linked to poorer outcomes due to increased bleeding and challenging patient profiles (2).  

Right heart bypass (RHB) is a technique in which the main pulmonary artery is cannulated for arterial inflow, and venous drainage is taken from both vena cavae. Its use in pediatric cardiac surgery procedures, such as the bidirectional Glenn shunt, Blalock-Taussig (BT) shunt, and pulmonary artery banding, has been described by Shivprakasha et al. (3).  

It has also been used for tricuspid valve replacement by Rim R and Uchida (4, 5). Uchida used an oxygenator in his version of the RHB circuit, whereas Rim R avoided an oxygenator, relying instead on the patient's native lung for oxygenation. 

Here the authors present the treatment strategy used in a patient who required redo tricuspid valve replacement. They modified the technique of right heart bypass without an oxygenator, as used by Rim R. An animation of the RHB circuit is shown in the video, along with a comparison to a conventional CPB circuit. The advantage of this circuit model is that, in the event of hemodynamic compromise, it can be seamlessly converted ed to a conventional cardiopulmonary circuit. This simplified approach also resulted in substantial cost savings by eliminating the oxygenator and reducing the need for additional circuit components. 

The patient was a 30-year-old female who was diagnosed with tricuspid valve endocarditis a year prior, who had undergone tricuspid valve repair for the same condition. She was discharged uneventfully, with a mild eccentric tricuspid regurgitation observed on echocardiography. She was kept on close follow-up with serial echocardiograms, which revealed worsening tricuspid regurgitation. Gradually, she developed facial puffiness and pedal oedema, and her echocardiography revealed severe tricuspid regurgitation. Consequently, the decision was made to proceed with a redo tricuspid valve replacement under right heart bypass. 

Her preoperative computed tomography revealed moderate cardiomegaly, with the right ventricle positioned close to the lower sternum. As a precaution, a decision was made to keep her femoral vessels exposed in case peripheral bypass was required. 

A standard midline redo sternotomy was performed, followed by adhesiolysis. The aorta, superior vena cava (SVC), and pulmonary artery were dissected out first. Systemic heparinization was administered using 3 mg/kg heparin. The main pulmonary artery was cannulated with an 18 French elongated one-piece arterial (EOPA) cannula, and the SVC was cannulated with a metal –tip, angled venous cannula. Right heart bypass commenced after the activated clotting time exceeded 300 seconds. The inferior vena cava (IVC) was dissected and cannulated, and both cavae were snared. 

The main pulmonary artery was cross-clamped proximal to the arterial cannula, and the right atrium (RA) was opened parallel to the atrioventricular groove.  

A soft sucker was placed at the coronary sinus to maintain a bloodless field. The tricuspid valve was then examined and found to have contracted leaflets  without any active lesions; hence, they were preserved. The previous tricuspid valve ring was carefully explanted.  

Ethibond 2-0 (26mm) pledgetted sutures were passed circumferentially, keeping the pledget on the right atrial side. Care was taken to avoid damaging the atrioventricular (AV) node and aortic valve while passing the sutures on the septal tricuspid leaflet (STL) annulus and the anterior tricuspid leaflet (ATL) annulus. 

It was safer to pass the needle on the STL and ATL rather than at the annulus in these sites to avoid injury to the AV node and the aortic valve. Any injury to the AV node could be recognized by a change in the native rhythm; if this occurred, the suture could be removed. 

Sizing of the valve annulus was performed using the standard method. As per patient choice, a tilting disc mechanical valve was used in this case. The valve was seated properly, and the sutures were tied carefully.  

The valve was then checked and rotated to ensure that the leaflets opened and closed fully. The right atrium was subsequently closed in a standard fashion. The pulmonary cross-clamp was removed, and the patient was gradually weaned off RHB. The patient was extubated four hours after surgery and discharged on postoperative (POD) day six. She experienced negligible drainage (100ml on POD 0) and showed rapid recovery with minimal inotropes.  

Her postoperative echocardiogram demonstrated a well-functioning valve with a gradient of 6/3, no tricuspid insufficiency, no paravalvular leak, and preserved left ventricular function. 

The technique of right heart bypass described here allowed for safe surgery on the right side of the heart. Procedures such as tricuspid valve surgery, pulmonary valve surgery, bidirectional Glenn, and BT shunt can be safely conducted using this technique (3–5). 

RHB offers several advantages, including reduced SIRS, avoidance of hypothermia, preservation of pulsatile flow, cost-effectiveness, no requirement for aortic cross-clamping, and avoidance of cardioplegia-related side effects. Additionally, during tricuspid valve replacement surgery, it enables intraoperative assessment for complete heart block during annular suture placement (4). 

References

1. ATILGAN K, DEMİRDAŞ E. Beating heart technique in tricuspid valve replacement among patients which have a TAPSE index lower than 15 mm. Journal of Surgery and Medicine. 2020 Mar 30;
2. Marin-Cuartas M, de Waha S, Saeed D, Misfeld M, Kiefer P, Borger MA. Considerations for Reoperative Heart Valve Surgery. Vol. 7, Structural Heart. Cardiovascular Research Foundation; 2023.
3. Shivaprakasha K, Rameshkumar I, Kumar RK, Nair SG, Koshy S, Sunil GS, et al. New technique of right heart bypass in congenital heart surgery with autologous lung as oxygenator. Annals of Thoracic Surgery. 2004;77(3):988–93.
4. Rim R. Tricuspid Valve Replacement Using Right Heart Bypass Without Cardiac and Pulmonary Ischemia. Tzu Chi Med J. 2008 Dec;20(4):318–21.
5. Uchida T, Sasako Y, Kobayashi J, Bando K, Minatoya K, Inamori S, et al. [Tricuspid valve replacement using right heart bypass in patient with liver cirrhosis]. Kyobu Geka. 2001 Feb;54(2):132–5.

Disclaimer

The information and views presented on CTSNet.org represent the views of the authors and contributors of the material and not of CTSNet. Please review our full disclaimer page here.