Cormatrix Patch Augmentation of the Tricuspid Valve Anterior Leaflet

Tricuspid regurgitation is most commonly treated by restrictive annuloplasty. However, this would not suffice for extreme annular dilatation and/or leaflet tethering. For these conditions, a patch augmentation of anterior or septal leaflets is sometimes necessary. In this video, the authors show their step-by-step approach to perform an anterior leaflet augmentation that allowed for the effective correction of a severe tricuspid regurgitation with annular dilation and complex tethering of the valve leaflets.

A 45-year-old woman was referred to the authors’ department for severe isolated tricuspid regurgitation. The patient was highly symptomatic (NYHA III-IV). The left and right ventricular function was normal. The pulmonary artery systolic pressure was 33 mmHg. The tricuspid ring diameter was 40 mm, and there was significant restricted motion of the anterior leaflet, in particular.

A standard horizontal right atriotomy was performed. The ring stitches were placed first to perfectly expose the valve. Then, a careful valve assessment was done and two stay sutures were placed to stretch the anterior leaflet. A complete detachment of the anterior leaflet was performed from commissure to commissure, at about 2-3 mm from the annulus. Four cardinal Prolene® 5-0 sutures were placed and a large patch of decellularized bowel mucosa was tailored to augment the leaflet. This was then sutured using cardinal stitches. Great care should be taken to avoid any purse string effect - this is achieved by holding the two extremities of the sutured segment by the assistant while tying. The ring size is generally chosen according to the dimension of the augmented anterior leaflet. In this case, the authors used a 28 prosthetic ring. The operation was completed in the usual fashion. The intraoperative transesophageal echocardiogram showed a good result with trace regurgitation. The patient went home on the eighth postoperative day without complications. The authors reviewed her in their outpatient department two years after surgery. She was asymptomatic and her tricuspid regurgitation was mild.

Leaflet patch augmentation is a simple technique that allows an optimal result in extreme cases of tricuspid regurgitation. It is important to perform it before ring implantation, as this may result in a more technically difficult procedure.

References

1. Cha BK, Kuh JH, Choi JB. Leaflet augmentation for treating tricuspid valve regurgitation: indications and the patch size. J Card Surg. 2015;30:903-904.
2. Myers PO, Kalangos A. Patch augmentation for tricuspid valve tethering. J Card Surg. 2013;28:730.