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Totally Endoscopic Late Tricuspid Valve Repair in IVD Abuser

Wednesday, January 11, 2023

Danesi TH. Totally Endoscopic Late Tricuspid Valve Repair in IVD Abuser. January 2023. doi:10.25373/ctsnet.21865593.v1



The patient featured in this video is a twenty-four-year-old woman with past medical history of intravenous drug abuse, ADHD, anxiety, depression, hepatitis C, PTSD, and morbid obesity, with a BMI of 31. She was admitted in February and April 2022 for recurrent tricuspid valve endocarditis. Blood cultures were positive for S. aureus, and a transthoracic echocardiogram (TTE) showed a 0.7 by 1.2 cm mobile vegetation on the tricuspid valve with associated moderate to severe regurgitation.

After completion of six weeks of antibiotic therapy, the patient underwent a drug screen. Once she was off antibiotics, a transesophageal echocardiogram (TEE) showed wide-open tricuspid regurgitation with a 0.8 by 1.1 cm mobile vegetation originating from the posterior leaflet. The patient also had severe annular dilatation. Major jets were seen coming from a 7.5 mm coaptation gap between the posterior leaflet, the anterior leaflet, and the anteroseptal commissure.

The patient was accepted for an endoscopic tricuspid valve repair. Because of the patient’s preferences, surgery was planned late in November, nine months after the diagnosis.

The Surgery

The preoperative assessment included left heart catheterization, which was unremarkable; right heart catheterization with an MPa of 18 mmHg, wedge of 12 mmHg, and RV pressure of 24 over 8 mmHg; and a CT angiography with Endoscopic Cardiac Surgeons protocol. Endoscopic Cardiac Surgery (ECS) CTA protocol includes a cardio-sync acquisition and post reconstruction of the heart, valve planes, and aorto-iliac vascular tree. Specific segmentation of the valves planes and chest wall are then performed to choose the best position for the working port.

Surgical setup included a 2 cm transaxillary working port through the fourth intercostal space and two 5 mm miniports placed into the third and fifth intercostal spaces, respectively. Through the upper port, a 6 mm trocar with CO2 insufflation and a 30-degree thoracoscope was placed. Pericardial retraction stitches and a ventline were passed through the lower port.

Cardiopulmonary bypass was instituted through a femoro-femoral surgical cannulation with a 2 cm micro incision above the groin. This decision was made because patent foramen ovale (PFO) was ruled out during the TEE and CT angiography surgery was planned on a beating heart. This approach allowed surgeons to identify any atrioventricular block caused by stitch placement close to the atrioventricular node.

Once cardiopulmonary bypass was initiated and some pleural adhesion was taken down, the phrenic nerve was identified, and the pericardium opened 3 cm above. The pericardiotomy was perfected, the pericardium retracted, and the oblique sinus opened. Despite not being mandatory in an endoscopic setting, superior vena cava (SVC) and inferior vena cava (IVC) were both snared to provide a clear operating field.

The opening of the transverse sinus was carried out carefully as to avoid any injury to the posterior SVC wall, the roof of the left atrium, or the lateral aspect of the aorta, which would have been difficult to repair in this setting. Briefly leaving some volume in helped to identify any bleeding source early.
After SVC and IVC were snared, the right atrium was entered and a ventline was inserted to drain the volume coming from the coronary sinus. The lower edge of the atriotomy was then tackled to the pericardium.

The atriotomy was then extended, and the upper edge of the atriotomy was tackled to the pericardium and, with a small suture catcher, pulled out from the chest. This maneuver provided an excellent opening of the right atrium, avoiding the need for any stiff retractor insertion.

To maximize exposure, the lowest edge of the atriotomy was retracted toward the diaphragm. Then the tip of the ventline was placed into the coronary sinus and secured to the posterior wall of the right atrium to keep it in place during the valve repair. Again, preoperative TEE and CT angiography excluded any PFO, allowing for a safe beating heart surgery. In addition, the fossa ovalis laid below the ventline.

Next, the tricuspid valve was assessed. Luckily, the infective process hadn’t affected the leaflets and their subvalvular apparatus too much. All three showed preserved flexibility, the septal leaflet was a tethered slightly because of right ventricle enlargement and the posterior leaflet showed a slightly dysmorphic aspect. The anterior leaflet was wide enough to provide a nice coaptation. The commissure between the septal and the posterior leaflet was remodeled, and the commissure between the anterior and the septal widely opened. In addition, the annulus was severely dilated.

A 34 mm rigid contour 3D annuloplasty ring was sized. Annular stitches were placed and, thanks to the beating heart approach, any conduction system disturbance like an iatrogenic atrioventricular block could be promptly identified.

To provide better support, some sutures relative to the lateral aspect of the annulus were passed twice. The ring was parachuted down and its sutures tightened with the Corknot fastener device.

A hydrotest showed a nicely closing valve with a small residual prolapse of the anterior aspect of the posterior leaflet. Shrinking the annulus with both double bite stitches and the rigid ring restored the normal shape of the commissures. The small prolapse was corrected by tightening its anterior and posterior aspect to the adjacent segments of the anterior and septal leaflet on a single CV6 Gore-Tex suture. This stitch provided a slight reduction and stabilization of commissures and corrected the prolapse. A new hydrotest showed a satisfying competence of the tricuspid valve.

The right atrium was then closed using a double Prolene 4-0 running suture.

Upon filling the heart, the TEE showed a nicely working tricuspid valve with mild residual tricuspid regurgitation and a mean gradient of two.

Next, caval snares were removed and the atriotomy was tested for bleeding. The oblique sinus, the left atrium roof, and the cavoatrial junction were carefully inspected for bleeding. A right ventricular temporary pacing wire was placed, as well as two 24 French drainages. The patient was weaned from the cardiopulmonary bypass after ninety-seven minutes of assistance without inotropes.

Finally, the pericardium was reapproximated, protamine administered, hemostasis perfected, the femoral cannulas were removed, and the chest ports and groin incision closed in a standard fashion.

The patient was extubated in the operating room and her hospital stay was uneventful. A predischarge TTE showed mild residual tricuspid regurgitation without significant transvalvular gradient and good biventricular function. An EKG showed normal sinus rhythm. The patient was discharged at home on postoperative day four.


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Dear Dr Danesi I also enjoyed the video and congratulations for the minimally invasive approach. In my experience with true tricuspid valve endocarditis, I don't seem to remember a case I did not have to intervene in some forms on the valve leaflets (mainly by reconstructing them and excluding all the infected native tissue). In your case it seems that the leaflets were not affected or not infected and the mechanism was mainly annulus dilatation with a small posterior leaflet prolapse? Did you find any vegetations? Thanks again for a nice video
This is, of course, a case of healed endocarditis with some residual regurgitant lesion as the operation was performed 9 months after the acute episode, a recurrence, something common in drug addicts. How was the TR graded as per the ASE? Which was the actual indication for surgery after so long? Right heart failure?. Thanks.

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