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Open Commissurotomy
• Open commissurotomy, which is rarely performed in the modern era, is indicated
for patients with pure MS with commissural fusion and with preserved leaet
mobility.
• Open commissurotomy is performed by sharply incising the fused valve commissures, with possible additional splitting of the papillary muscle or fenestration of fused chordae.
Mitral Valve Replacement (MVR)
• Unlike in MR, in which the tissue is relatively pliable and amenable to repair, the
signicant brosis associated with MS often necessitates an MVR if an operation is indicated.
• In a chordal-sparing MVR, attempts are made to preserve the papillary muscles
and the posterior leaet in order to preserve ventricular geometry, which improves
post-operative outcomes.
• Operative steps:
– The MV is accessed as described above for MV repairs.
– The anterior leaet must be transferred to prevent LVOT obstruction. It is
detached from the annulus and divided into two segments with strong primary
chords and the segments are re-anchored with valve sutures to their corresponding commissures.
– The posterior leaet is left intact, and the valve leaet is incorporated into the
valve sutures.
– If the leaets are too calcied and cannot be preserved, they are excised to
prevent outow tract obstruction.
– Horizontal mattress sutures are placed circumferentially around the mitral
annulus in an everting or non-everting fashion, and the valve is tied down.
– For mechanical valves, the prosthetic valve should be oriented in an anti-
anatomic fashion (valve leaets perpendicular to the orientation of the native
leaets) to improve leaet clearance and reduce the risk of a “lazy leaet.”
Bioprosthetic valves should be oriented with two posts facing the trigones and
one post dividing the posterior annulus.
G. Leya and S. Melnitchouk
Mechanical Versus Bioprosthetic MVR
• The decision between a mechanical or bioprosthetic MV depends on durability,
risks associated with anticoagulation, and patient preference.
• Both the ACC and AHA recommend mechanical prosthesis for patients younger
than 60, and bioprosthetic valves for patients older than 70, primarily guided by
higher rates of eventual valve degeneration and re-operation in younger patients.
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161
Between 60 and 70years of age, either mechanical or bioprosthetic valves can be
used depending on the relative risks and benets of anticoagulation and valve
longevity for the individual patient.
• Bioprosthetic valves are chosen if there is any contraindication to anticoagulation, or during pregnancy or women of child-bearing age.
Special Operative Considerations [4–7, 16]
Mitral Annular Calcication
• Mitral annular calcication (MAC) is the phenomenon of signicant calcium
deposits in the mitral annulus, primarily along the posterior annulus but sometimes circumferentially.
• MAC complicates MV operations since it increases the risks of atrioventricular
disruption, paravalvular leak, and valve dehiscence after valve replacement.
• MAC is managed in various ways, depending on tissue quality and age of the
patient. In some cases, the sutures can be passed behind the MAC.Because of
irregularity of the calcium bar, a felt gasket can be tailored using a bioprosthetic
valve sizer. The gasket is then placed between the annulus and the sewing ring of
the valve in order to reduce the risk of paravalvular leak in the future. MAC can
also be partially debrided either using a rongeur or CUSA (cavitron ultrasonic
aspirator), thus allowing placement of the valve sutures through the remaining
calcium bar. MAC can also be completely excised, especially in younger patients
with stronger tissue quality. Complete excision is achieved by separating the
posterior leaet from the annulus, removing the calcium “en bloc,” and repairing
the defect with a pericardial patch to mitigate the risk of atrioventricular groove
disruption.
• Aggressive MAC debridement or placement of an oversized valve prosthesis can
be complicated by AV groove disruption, or separation of the LA and LV due to
rupture of the LV near the AV groove posteriorly. This manifests as bright red
hemorrhage stemming from behind the heart upon release of the aortic clamp.
Management requires going back on bypass, rearresting the heart, removing the
old valve prosthesis, and internal repair of the defect using a pericardial patch
followed by valve re-replacement.
References
1. Cohn LH.The rst successful surgical treatment of mitral stenosis: the 70th anniversary of
Elliot Cutler’s mitral commissurotomy. Ann Thorac Surg. 1993;56(5):1187–90.
2. Otto CM, etal. 2020 ACC/AHA guideline for the management of patients with valvular heart
disease: a report of the American College of Cardiology/American Heart Association joint
committee on clinical practice. Circulation. 2021;143(5):e35.
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3. Carpentier A, Adams D, Filsou F.Carpentier’s reconstructive valve surgery. St. Louis, MO:
Elsevier; 2010.
4. Goldstone A, Woo J.Chapter 80: Surgical treatment of the mitral valve. In: Sabiston & Spencer
surgery of the chest. 9th ed. Philadelphia, PA: Elsevier; 2016. p.1384–429.
5. Anyanwu A, etal. Chapter 92: Ischemic mitral regurgitation. In: Sabiston & Spencer surgery
of the chest. 9th ed. Philadelphia, PA: Elsevier; 2016. p.1624–52.
6. Cohn LH, McClure RS.Chapter 42: Mitral valve repair. In: Kaiser’s mastery of cardiothoracic
surgery. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2014. p.407–18.
7. Chan V, et al. Chapter 44: Mitral valve repair for ischemic mitral regurgitation. In: Kaiser’s
mastery of cardiothoracic surgery. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins;
2014. p.419–39.
8. Dal-Bianco JP, Levine RA. Anatomy of the mitral valve apparatus. Cardiol Clin.
2013;31(2):151–64.
9. Coffey S, etal. The modern epidemiology of heart valve disease. Heart. 2016;102:75–85.
10. Anyanwu AC, Adams DH. Etiologic classication of degenerative mitral valve disease:
Barlow’s disease and broelastic deciency. Semin Thorac Cardiovasc Surg. 2007;19:94.
11. Zoghbi WA, et al. Recommendations for noninvasive evaluation of native valvular regurgitation. J Am Soc Echocardiogr. 2017;30(4):303–71.
12. Baumgartner H, etal. Echocardiographic assessment of valve stenosis: EAE/ASE recommendations for clinical practice. Eur J Echocardiogr. 2009;10:1–25.
13. DiBardino D, etal. Four decades of experience with mitral valve repair: analysis of differential indications, technical evolution, and long-term outcome. J Thorac Cardiovasc Surg.
2010;139(1):76–83.
14. Suri RM, etal. Association between early surgical intervention vs watchful waiting and outcomes for mitral regurgitation due to ail mitral valve leaets. JAMA. 2013;310:609–16.
15. Acker MA, etal. Mitral-valve repair versus replacement for severe ischemic mitral regurgitation. NEJM. 2014;370(1):23–32.
16. Yun KL, etal. Randomized trial comparing partial versus complete chordal-sparing mitral
valve replacement: effects on left ventricular volume and function. J Thorac Cardiovasc Surg.
2002;123(4):707–14.
17. David TE, etal. Late outcomes of mitral valve repair for mitral regurgitation due to degenerative disease. Circulation. 2013;127(14):1485–92.
18. Gillinov AM, etal. Valve repair versus valve replacement for degenerative mitral valve disease.
J Thorac Cardiovasc Surg. 2008;135(4):885–93.
19. Kaneko T, et al. Mechanical versus bioprosthetic mitral valve replacement in patients <65
years old. J Thorac Cardiovasc Surg. 2014;147(1):117–26.
20. Chan KMJ, etal. Coronary artery bypass surgery with or without mitral valve annuloplasty in
moderate functional ischemic mitral regurgitation: nale results of the randomized ischemic
mitral evaluation (RIME) trial. Circulation. 2012;126(21):2502–10.
21. DiBardino DJ, etal. Four decades of experience with mitral valve repair: analysis of differential indications, technical evolution, and long-term outcomes. J Thorac Cardiovasc Surg.
2010;139(1):76–83.
22. Bax JJ, et al. Restrictive annuloplasty and coronary revascularization in ischemic mitral
regurgitation results in reverse left ventricular remodeling. Circulation. 2004;110(11 Suppl
1):II103–8.
23. Deja MA, etal. Inuence of mitral regurgitation repair on survival in the surgical treatment for
ischemic heart failure trial. Circulation. 2012;125(21):2639–48.
24. Castillo JG, etal. A near 100% repair rate for mitral valve prolapse is achievable in a reference
center: implications for future guidelines. J Thorac Cardiovasc Surg. 2012;144(2):308–12.
25. David TE, etal. Chordal replacement with polytetrauoroethylene sutures for mitral valve
repair: a 25-year experience. J Thorac Cardiovasc Surg. 2013;145(6):1563–9.
26. Goldstein D, etal., for the CTSN.Two-year outcomes of surgical treatment of severe ischemic
mitral regurgitation. N Engl J Med. 2016;374(4):344–53.
G. Leya and S. Melnitchouk
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27. Michler RE, etal., for the CTSN.Two-year outcomes of surgical treatment of moderate ischemic mitral regurgitation. N Engl J Med. 2016;374(20):1932–41.
28. Brown ML, etal. Systolic anterior motion after mitral valve repair: is surgical intervention
necessary? J Thorac Cardiovasc Surg. 2007;133(1):136–43.
29. Wilkins GT, etal. Percutaneous balloon dilatation of the mitral valve: an analysis of echo. Br
Heart J. 1988;60:299–308.
30. Bouleti C, etal. Reinterventions after percutaneous mitral commissurotomy during long-term
follow-up, up to 20 years: the role of repeat percutaneous mitral commissuorotmy. Eur Heart
J. 2013;34:1923–30.
31. Marijon E, etal. Rheumatic heart disease. Lancet. 2012;379:953–64.
32. Chandrashekhar Y, etal. Mitral stenosis. Lancet. 2009;374:1271–83.
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Chapter 15
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Tricuspid Valve Repair andReplacement
ElaineM.Griffeth andJosephA.Dearani
Learning Objectives
• Basic introduction to valve pathologies
• Indications for repair vs. replacement
• Repair techniques
• Replacement technique
• Prosthesis selection
Introduction
In general, cardiac valvular pathology is characterized as regurgitant, stenotic,
atretic, or displaced. Tricuspid valve pathology is predominantly regurgitant due to
annular dilation and leaet tethering secondary to right ventricular dilation. This
right ventricular dilation is generally a result of volume or pressure overload, as
seen in patients with pulmonary hypertension (primary or secondary due to leftsided heart disease) or dilated cardiomyopathy. Operative management of this condition centers on tricuspid valve repair with annuloplasty, and outcomes are better
if surgery is performed prior to the onset of right ventricular systolic dysfunction.
E. M. Griffeth · J. A. Dearani (*)
Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, USA
e-mail: griffeth.elaine@mayo.edu; jdearani@mayo.edu
Switzerland AG 2024
J. P. Bloom, T. M. Sundt (eds.), Cardiac Surgery Clerkship, Contemporary
Surgical Clerkships, https://doi.org/10.1007/978-3-031-41301-8_15
165© The Author(s), under exclusive license to Springer Nature
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A small number of congenital heart disease patients are present with atretic or displaced tricuspid valve pathology, which require more complex repair techniques.
E. M. Griffeth and J. A. Dearani
Anatomy
Embryology: The atrioventricular (AV) valves arise from the endocardial cushion.
This embryonic structure also gives rise to the semilunar valves and atrial and ventricular septae.
The tricuspid valve is the right-sided AV valve and is composed of a saddleshaped annulus, three leaets (anterior, septal, posterior), and subvalvar apparatus
including chordae tendineae and papillary muscles.
Please refer to Chap. 2 of this book for more detailed descriptions of valvular
anatomy.
Pathology
Primary Tricuspid Regurgitation
Congenital
• Ebstein anomaly—displacement of tricuspid valve posteriorly and septal leaet
inferiorly into the right ventricle, resulting in atrialization of a portion of the right
ventricle; associated with atrial septal defects (ASD).
• Congenital tricuspid valve dysplasia—morphologically abnormal valve leaets
and/or subvalvular apparatus (e.g., shortened chordae).
• Endocardial cushion defect (partial or complete atrioventricular septal defect
[AVSD])—regurgitant common AV valve resulting from malformation of septae
and AV valves from endocardial cushion.
Acquired
• Endocarditis—most common pathogens are staphylococcus and streptococcus;
see Chap. 17 for additional information.
• Rheumatic heart disease—valve damage is immune-mediated via a type II
hypersensitivity reaction (not due to direct damage from bacteria); can also cause
tricuspid stenosis.
• Carcinoid heart disease.
• Myxomatous degeneration (connective tissue disorders).
• Iatrogenic—transvenous pacing leads, endomyocardial biopsy.
• Radiation.
• Trauma.
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Secondary (Functional) Tricuspid Regurgitation
• Annular dilation is the most common cause of tricuspid regurgitation; the resul-
tant change in shape of the annulus from oval to circular leads to leaet tethering
and limited coaptation.
– This can occur in patients with atrial brillation in the absence of both pulmo-
nary hypertension and left-sided heart disease.
• Pulmonic stenosis, especially if right ventricular systolic pressure (RVSP) is
>55mmHg.
• Pulmonary hypertension.
Tricuspid Stenosis
• Rheumatic heart disease.
• Carcinoid heart disease.
• Tumor/thrombus (e.g., patients with advanced renal cell carcinoma can have
tumor thrombus extending from inferior vena cava (IVC) through right atrium
and across the tricuspid valve, effectively narrowing the valve orice).
Tricuspid Atresia
• Failure of the tricuspid valve to form, resulting in hypoplasia of the right ventri-
cle chamber and outow tract; associated with ASD and ventricular septal defect
(VSD). An ASD is required for post-natal viability with staged palliation in a
single ventricle treatment pathway towards the Fontan procedure.
History andPhysical Exam
Patients may present with symptoms of right heart failure, which include fatigue,
decreased appetite, ascites, peripheral edema, and low albumin. The provider should
perform a physical exam, looking for signs of right heart failure and its potential
causes such as left heart pathology, right-sided valvular disease, or cor pulmonale.
Physical Exam Findings
• Neck: Jugular venous distension, including a prominent “v” wave indicating tri-
cuspid regurgitation.
• Pulmonary: Signs of pulmonary disease in patients with cor pulmonale, such as
increased thoracic anteroposterior diameter and expiratory wheezing in patients
with chronic obstructive pulmonary disease (COPD).
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• Cardiac:
– Systolic murmurs:
Tricuspid regurgitation: holosystolic, high-pitched “blowing” murmur,
intensity may increase with inspiration.
– Diastolic murmurs:
Tricuspid stenosis: mid to late diastolic, delayed “rumbling” murmur.
– Right-sided S3 “gallop” indicates right ventricular volume overload and right
heart failure.
• Abdomen: Hepatomegaly, ascites.
• Extremities: Peripheral edema, especially in the ankles in ambulatory patients.
Symptoms or signs of right heart failure should raise concern for decompensated
tricuspid regurgitation. Due to increased risk for operative mortality, the patient
should be admitted and medically optimized prior to surgical intervention. Patients
with tricuspid stenosis can present with signicantly reduced cardiac output.
E. M. Griffeth and J. A. Dearani
Imaging
Echocardiography
• Transthoracic echocardiography (TTE): The main imaging modality used for
evaluation of the tricuspid valve; allows for differentiation of primary and sec-
ondary causes of tricuspid valve pathology, assessment of the right and left heart
function, and measurement of right sided pressures.
• Transesophageal echocardiography (TEE): Used intraoperatively to assess the
valve pre- and post-bypass.
Please refer to Chap. 4 for additional details on echocardiography.
Cross-Sectional Imaging
• Cardiac MRI: Used to assess the right ventricle size and function. The tricuspid
valve is also assessed but echocardiography is often preferred for valvular ana-
tomic detail.
Please refer to Chap. 5 for additional details on cardiac MRI.
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Cardiac Catheterization
• Right heart catheterization: Used to assess hemodynamics and to evaluate the
right heart in the case of discordant imaging and/or exam ndings.
Please refer to Chap. 6 for additional details on cardiac catheterization.
In patients presenting with tricuspid regurgitation, always evaluate for left-sided
pathology and/or pulmonary hypertension, especially in the setting of structurally
normal valves.
Indications forIntervention
Surgical outcomes and survival are better if surgery is performed prior to the onset
of right ventricular systolic dysfunction. End-organ damage such as liver or kidney
failure markedly affects survival, as does reoperation for severe, isolated tricuspid
regurgitation after left-sided valve surgery [1]. Additionally, there is an increased
risk of right ventricular failure after operation for patients with severe right ventricular systolic dysfunction or irreversible pulmonary hypertension preoperatively
[1]. The above factors are important to consider when evaluating patients for potential surgical intervention.
The indications for intervention are based on the severity of valvular disease and
patient symptoms. Tricuspid regurgitation can be categorized into three stages
(B-progressive, C-asymptomatic severe, and D-symptomatic severe) based on
patient symptoms and valve hemodynamics as measured with echocardiography
[1]. Serial measurements must be obtained because tricuspid regurgitation is
dynamic and affected by preload. Tricuspid stenosis is categorized as severe (Stages
C and D) based on echocardiographic evaluation [2].
Tricuspid Regurgitation
• Surgical treatment of tricuspid regurgitation at the time of surgery for left-sided
valve pathology is performed in cases of moderate or severe tricuspid regurgita-
tion (Stages C and D) and to prevent the development of severe tricuspid regur-
gitation in cases when progressive tricuspid regurgitation can be expected
(Stage B) [1].
– These are the most common indications for tricuspid valve surgery. The previ-
ously held belief that right heart dilatation and tricuspid regurgitation would
auto-correct following correction of left-sided pathology has been shown to
be frequently incorrect [3–7].
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• Isolated tricuspid valve surgery is indicated in patients with severe symptomatic
tricuspid regurgitation (Stage D) either due to primary disease (e.g., structural or
device lead damage) or secondary disease poorly responsive to medical therapy
but in the absence of left-sided pathology and pulmonary hypertension, as seen
in patients with atrial brillation [1].
• Isolated tricuspid valve surgery can be considered on a case-by-case basis for
patients with severe asymptomatic (Stage C) primary tricuspid regurgitation and
progressive right ventricular dilatation or systolic dysfunction, or severe symp-
tomatic (Stage D) tricuspid regurgitation who have previously undergone left-
sided valve surgery but do not have severe pulmonary hypertension or severe
right ventricular systolic dysfunction [1].
E. M. Griffeth and J. A. Dearani
Tricuspid Stenosis
• Surgical treatment is recommended for patients with severe tricuspid stenosis at
the time of operations for left-sided valve disease and for isolated, symptomatic
severe tricuspid stenosis [2].
Congenital Heart Disease
• Ebstein anomaly
– Surgical repair is indicated if there is signicant tricuspid regurgitation and
one or more of the following are present: heart failure symptoms, objective
evidence of worsening exercise capacity, progressive right ventricular systolic
dysfunction by echocardiography or cardiac MRI, progressive right ventricular enlargement, systemic desaturation from right-to-left atrial shunt, paradoxical embolism, and/or atrial tachyarrhythmias [8].
• Congenital tricuspid valve dysplasia
– Surgical repair is considered on a case-by-case basis in patients who have
developed symptoms of right heart failure, arrhythmias, or progressive right
ventricular dysfunction on imaging. Decisions regarding intervention are also
informed by the indications listed above for tricuspid regurgitation.
• Endocardial cushion defects
– Surgical repair is usually performed early in life (by age 6months) to prevent
irreversible pulmonary vascular disease resulting in Eisenmenger physiology [8].
– If right AV valve regurgitation and/or stenosis develop later, valve surgery can
be considered on a case-by-case basis. However, primary repair of AVSD or
closure of residual shunts should not be performed if pulmonary artery systolic pressure is greater than two-thirds systemic, pulmonary vascular resistance is greater than two-thirds systemic, or there is a net right-to-left shunt [8].
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