In this CTSNet series, Dr. Mario Castillo-Sang presents innovative, totally endoscopic cardiac procedures for a variety of conditions. Stay tuned for more series videos [3] in the coming weeks.    

The authors present the case of a 54-year-old female with a history of intravenous drug abuse (IVDA) who was now in remission. She had been treated several years prior for acute bacterial endocarditis medically. Although she healed successfully from the endocarditis, it resulted in torrential tricuspid valve regurgitation. The patient complained of extreme fatigue, lower extremity edema, and abdominal fullness. She also had a history of septic pulmonary emboli, which led to the development of empyema requiring chest tube drainage. 

The patient was offered an endoscopic tricuspid valve repair with a backup replacement using a bovine pericardial valve. She was counseled that there was a significant possibility of requiring a sternotomy.  

The endoscopic approach consisted of a working incision of  2.5 cm incision in the fourth intercostal space, which was expanded with an extra-small soft tissue retractor and no rib spreader. The camera port was a 10 mm trocar in the third intercostal space, and a 5 mm incision was made in the fourth anterior intercostal space for the atrial lift retractor. Femoral bypass via cutdown with direct arterial and venous cannulation is standard; however, in cases requiring full cardiopulmonary bypass isolation, a bicaval strategy was performed with a right internal jugular 17 Fr cannula and a femoral 25 Fr cannula. In this case, which involved a more complex tricuspid valve repair, the authors favored cardioplegic arrest of the heart with bicaval cannulation. This approach is also advantageous for cases in which the heart is significantly rotated, with a long superior vena cava (SVC) very close to the diaphragm and the aortic root protruding into the right atrium, obstructing the view of the tricuspid valve through the right atriotomy. 

Valve analysis showed that the anterior leaflet had lost its chordae, so the authors’ strategy was to reanchor the segment with a polytetrafluoroethylene (PTFE) neochordae and bicuspidize it to the posterior leaflet. This was achieved with CV5 PTEF, and the neochordae was CV4 PTFE. A 26 mm incomplete tricuspid band was used, resulting in trace residual tricuspid regurgitation with a mean gradient of 1 mmHg. The patient made a full recovery and was discharged home on postoperative day five. At a six-month follow-up, the patient was doing well. 

Endoscopic tricuspid valve repair surgery can be performed successfully with the beating heart, fibrillating, or arrested (1). For more complex cases, the authors advocate for the latter two options, understanding that this negates the ability to observe the cardiac rhythm. Preparation for possible epicardial lead placement is important. 

References

1. Malik MI, Chu MW. The 10 Commandments for Endoscopic Minimally Invasive Tricuspid Valve Repair. Innovations. 2024 May;19(3):219-26.

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