Tricuspid Valve Replacement

John R. Dory, MD, and Donald B. Dory, MD

Perations on the tricuspid valve are usually per-
O formed in conjunction with treatment of some other
valvular heart disease. Most commonly, the morphology
of the tricuspid valve is dilation of the anulus secondary to
pulmonary hypertension and right ventricular dilation
associated with mitral or combined mitral and aortic
valve disease. Anular dilation results in tricuspid valve
regurgitation. The tricuspid valve leaflet tissues are nor-
mal or near normal so that repair of the tricuspid valve by
anuloplasty techniques is nearly always possible and tri-
cuspid valve replacement is sddom necessary.
There are some pathologic processes that directly involve
the tricuspid valve leaflet tissues. Valve repair may not be
possible, and replacement is required. Tricuspid valve en-
docarditis, acute or subacute, may result in destruction of
enough leaflet tissue to require valve replacement. Endocar-
ditis may be associated with pacemaker electrodes passed
through the venous system adherent to the tricuspid valve
and lodged in the right ventricle. Rheumatic heart disease
may affect the tricuspid valve in conjtmction with other
cardiac valves. 1 The morphology is valve leaflet thickening
and retraction with commissural fusion resulting in tricuspid
valve stenosis and/or regurgitation. Carcinoid tumors pro-
ducing serotonin (t-hydroxytryptamine) may destroy the tri-
cuspid valve (and pulmonary valve) by cicatricial changes in
leaflet tissues causing tricuspid stenosis and regurgitation.2
Similar changes are seen in patients using phentermine-fen-
floramine for appetite control. Tricuspid valve regurgitation,
commonly associated with cardiac transplantation,3 may be-
come severe when associated with ruptured chordae tendi-
nae from multiple right heart biopsies. There are some tri-
cuspid valves affected by Ebstein's anomaly40z that are so
severely deformed that repair is either ineffective or impos-
sible so that valve replacement is necessary.
Methods of tricuspid valve replacement are detailed
in this paper.

leaflet Coronary sinus

| Tricuspid valve replacement with mechanical or stented bioprosthetic valve. Tricuspid valve operations are
performed via a standard midline sternotomy (complete or lower one half) or through an anterior thoracotomy on the
right side. Cardiopulmonary bypass is established using two cannulae for venous uptake (inset figure) with oxygenated
blood returned to a cannula placed in the ascending aorta. Tourniquets are secured around the vena cavae and cannulae
to isolate the right atrium. Some operations lend well to continuous coronary perfusion, but most procedures are
performed with the aorta occluded and the heart arrested by cold cardioplegic solution administered through a catheter
in the coronary sinus. The tricuspid valve is excised beginning with the anterior leaflet, continuing around the posterior
leaflet, and finally completing the excision over the septal leaflet. Nearly all or at least a considerable rim of the septal
leaflet of the tricuspid valve should be preserved for attachment of the valve prosthesis. The appropriate size valve
prosthesis is selected based on measurements using valve anulus calibrators.
Operative Techniques in Thoracic and Cardiovascular Surgery, Vol 8, No 4 (November), 2003: pp 193-200 193
 Septal
leaflet

Atri0ventricular uoronary
node sinus
2 Pledger reinforced mattress sutures are used to buttress and strengthen the tissue repair of the septal leaflet of the
tricuspid valve. The stitches are placed through only leaflet tissue at the apex of the triangle of Koch to preserve the integrity
and function of" the electrical conduction system. The rest of septal portion of the anulus is repaired by pledger-reinforced
sutures passed around the anulus and leaflet remnant. The sutures are passed through the sewing ring of the prosthesis as the
stitches are placed in the septal leaflet.

Tricuspid
valve
anulus

3 The prosthesis is attached to the rest of the anulus by continuous stitches using 2/0 polypropylene suture material. The
continuous suture is started as a pledget-reinforced mattress stitch placed around the anulus anteriorly and brought through the
sewing ring of the prosthesis. The prosthesis is placed in the right ventricle and the suture tightened to approximate the sewing ring
of the prosthesis to the valve annulus. Stitches are placed from the anulus to the sewing ring of the prosthesis, worldng in a clockwise
fashion. Tension is n|aintained on the suture to approximatel the tissues firmly to the sewing ring of the prosthesis. Tension is
released with each needle pass to facilitate exposure of the junction of ventricular myocardium and the anulus.
TRICUSPID VALVE REPLACEMENT 195

Tricuspid
valve
anulus

-~i ~'
~=s 7i7 i:i=
W ~S

R iI)IIIIII!IIIIIIIIIII(
2;"

i7 J

4 The stitches are continued to the junction of the anulus of the free wall with the septum. The remainder of the repair
is done using the needle at the opposite end of the suture working in a counterclockwise fashion. The needle is passed from
the tricuspid anulus to the sewing ring of the prosthesis, continuing to the commissure between septal and anterior leaflets.
 /~"/ iii ,:,i: ~ ~i? I ii~ ii~ii:i i

Atriow
node

Completed repair
5 The valve replacement is completed by tying sutures securely. An alternate technique involves using all interrupted
pledgeted mattress stitches when the tricuspid leaflet tissue and annulus is delicate and not as likely to hold secure with
continuous suture technique.

Mitral valv~
homograft

6 Tricuspid valve replacentent with mitral valve homograft. The tricuspid valve is excised and the diameter of the anulus
is measured as described above. A mitral valve homograft of the salne anular diameter is chosen. The homograft is
cryopreserved and must be thawed, a process that takes approximately 20 minutes. The homograft is trimmed after thawing.
The myocardium of the atrium and the ventricle is cut away from the anulus of the homograft, leaving just enough tissue to
allow needle penetration without entering leaflet tissue The papillary muscles are shortened, leaving l0 mm of muscle below
the chordal attachments.
 Tricuspid
valve
anulus Anterior
papillary
muscle

Atr~ . . . . . . . . ]

node sinus
7 Horizontal mattress stitches (2/0 braided polyester) for auuloplasty are placed through the annlus of the tricuspid valve except
for the area occupied by the septal leaflet. These stitches are placed using both needles of a double needle suture passed from the
right ventricle to the right atrium through the tricuspid valve anulus. The sutures are placed as the initial step of the operation, as
it is easier than after the homograft is in place, exposure is enhanced, and this cml be performed during the homograft thawing
process. The anterior papillary muscle of the tricuspid valve is the only one suitable for attachment of the homograft papillary
muscle. This papillary muscle supports all of the anterior and part of the posterior leaflets of the tricuspid valve, is usually of good
size, and is continuous with the moderator band, which can provide additional support.

Septal
leaflet

M
tri

8 The mitral homograft is oriented with its anterior leaflet to the ventricular septum (septal leaflet area of the tricuspid
valve). Orientation is maintained by placing a stitch of 4/0 polypropylene through the fibrous trigones at each end of the
homograft anterior leaflet and passing the stitches through recipient tricuspid valve anulus or leaflet remnant at each end of
the septal leaflet.
198 DOTY AND DOTY

The anterior papillary muscle

of the mitral homograft is positioned
side-by-side to the anterior papillary
muscle of the recipient tricuspid
valve using a horizontal mattress
stitch (inset figure). Firm attachment
of the donor papillary muscle to the
patient papillary muscle is accom-
plished using 8 to 10 simple stitches of
fine monofilament suture (5/0 Cardio-
nylTM). A channel is made through the
anterior wall of the right ventricle at
an appropriate position to accommo-
date the posterior papillary muscle of
the homograft. The papillary muscle
is pulled through the channel. It is
secured to the epicardial surface of
the right ventricle with multiple
kl I L ~ ! I U I
stitches of 5/0 Cardionyl TM suture.
~.apillary The homograft papillary muscle is
muscle also secured to the endocardial sur-
face with multiple sutures.

~L

Tricuspid
valve
anulus
jJ
.:S

Mitral ~I ~
valve "
homograft
][ O The anulus of the homograft is attached to the anulns of the recipient by continuous stitches of 4/0 polypropylene
sutures using the stitches previously placed in the fibrous trigones of the homograft. The stitches are placed around the anulus
of the patient tricuspid valve and through the atrial remnant and anulus of the homograft.
 At~
fig

Completed repair ....... ....

][ ][ An anuloplasty band (Cosgrove Anuloplasty Band TM, Edwards LifeSciences, Anaheim, CA) or pericardial strip is used
to support the tricuspid anulus in the portions occupied by the anterior and posterior leaflets. The septal portion is not
supported. The anuloplasty band is attached to the tricuspid valve anutus by the previously placed mattress sutures. The
anuloplasty band is tied securely to the tricuspid anulus to complete the valve replacement.

|~ 2 Photograph of tricuspid valve replacement with mitral valve homograft supported by Cosgrove Anuloplasty Band TM.
200
COMMENTS
Replacement of the tricuspid valve is not often re-
quired but there are some conditions in which the
valve leaflet tissue is deficient or even destroyed to a
degree that valve repair is not possible. Operations
on the tricuspid valve are usually done concomi-
tantly with operations on other c a r d i a c valves. Iso-
lated tricuspid valve replacement is a high risk pro-
cedure with 30-day hospital mortality in the range of
10% to 24%.6-a Complete heart block requiring pace-
maker insertion as a complication of tricuspid valve
replacement occurred in 28% of 32 patients reported
by Do and associates. 9 Choice of replacement device
is not conclusive. Significant advantage has not been
demonstrated comparing mechanical prostheses to
stent-mounted bioprostheses.7,8,1~ Tricuspid valve
replacement with mitral valve homograft may offer
some advantages in patients with tricuspid valve en-
docarditis, ~2-~4 especially those infected with drug-
resistant bacteria or fungus.
REFERENCES
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after heart transplantation. J Heart Lung Transplant 20:709-717,
2001
DOTY AND DOTY
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From the Division of Cardiothoracie Surgery, The Johns Hopkins Hospital,
Bahimore, MD, and LDS Hospital, Salt Lake City, UT.
Address reprint requests to Donald B. Doty, M1), 324 Tenth Avenue, Salt Lake
City, Utah 84103; e-mail: LDDDOTY@IHC.COM
9 2003 Elsevier Inc. All rights reserved.
1522-2942/03/0804-0007530.00/0
doi:10, l O53/S1522-9042(O3)OOO44-X