Brief Case Description

The patient is a 64 year-old male with asymptomatic severe mitral regurgitation followed by his cardiologist for several years and now presenting with worsening left ventricular function (See type II dysfunction). He underwent an AICD insertion for several episodes of ventricular arrhythmia.

Transthoracic and transesophageal echocardiography showed type II mitral valve dysfunction with posterior leaflet prolapse. There was moderate (3+) tricuspid regurgitation due to type I dysfunction with significant annular dilatation. Right ventricular function was moderately decreased.

The patient was referred for reconstructive mitral and tricuspid valve surgery. Here we only describe the surgical management of functional tricuspid regurgitation.

Operative Procedure

Intraoperative Transesophageal Echocardiography

Intraoperative transesophageal echocardiography confirmed type I tricuspid valve dysfunction. Tricuspid annulus was significantly dilated. Semi-quantitative measurement showed moderate (3+) tricuspid regurgitation.

Tricuspid Valve Analysis

Following the right atriotomy, we first performed valve analysis which showed significant tricuspid annular dilatation (type I dysfunction). The morphology of all three leaflets was normal and their motion was preserved. The lead of the AICD did not compromise the motion of the septal leaflet.

Following this complete echocardiographic and operative valve analysis, we can summarize the pathophysiological triad as follows:

Etiology : Functional tricuspid regurgitation

Lesions : Annular dilatation

Dysfunction: Type I

Reconstructive Procedure

We performed a tricuspid remodeling annuloplasty. Annular sutures were placed around the tricuspid annulus. The first septal suture was placed at the level of the hinge to prevent injury to the bundle of His. At the posterior portion of the annulus, care was taken to direct the tip of the needles toward the ventricle to avoid right coronary artery injury.

Ring selection was based on the following two measurements:

first, measurement of the base of the septal leaflet

second, surface area of the leaflet tissue attached to the chordae arising from the anterior papillary muscle.

In this case, a 34 mm Carpentier Edwards Physio tricuspid ring was implanted.

Postbypass Transesophageal Echocardiography

Postbypass transesophageal echocardiography showed a competent tricuspid valve with no residual regurgitation.