Minimally Invasive Complex Tricuspid Valve Repair

Case

The patient is a 59-year-old woman with severe tricuspid regurgitation from a septal leaflet restriction by a pacemaker lead implanted for sick sinus syndrome. The patient complained of fatigue and leg swelling. Workup demonstrated normal coronaries, normal left ventricular ejection fraction, and good function of the mitral valve. She was offered a fourth space right minithoracotomy tricuspid valve repair. 

The operation was performed with femoral cardiopulmonary bypass and beating heart with caval isolation using umbilical tapes. 

The atrium was opened in the standard fashion, and it was immediately apparent that the right ventricular lead is densely attached to the septal leaflet. Static valve testing showed that the septal leaflet was indeed restricted. The unroofing of right ventricular lead was undertaken with a 15-blade scalpel in a tedious process that required gentle scoring of the scar over the lead and eventual use of the cautery with low energy. Once the lead was freed, the valve was tested and competence was appreciated. Given the goal of preserving the lead, the approach taken was to lock the lead between the septal and posterior leaflets and bicuspidizing the valve suturing these two leaflets. The annular sutures were placed and a 28 mm incomplete band was secured.

Static testing showed no residual tricuspid regurgitation. The right atrium was closed, and postcardiopulmonary bypass echocardiogram showed no residual regurgitation with a mean gradient of 2 mm Hg.

The patient was discharged home on postoperative day four and had full recovery. Her pacemaker continued to work without issues.

Discussion

Tricuspid valve regurgitation secondary to pacemaker leads is more frequently recognized today (1). Correction of this problem requires early identification as well as surgical intervention. Often, removing the lead from the leaflet is not possible, and in these circumstances a tricuspid valve replacement may be needed if other techniques such as bicuspidization are not possible.

Approach to the tricuspid valve via a right minithoracotomy is a well-established technique to address the valve (2). Careful manipulation of the scar tissue over the lead can yield salvage of the lead and repair of the valve. When performed with a minimally invasive approach, the operation offers patients a faster recovery.

References

1. Chang JD, Manning WJ, Ebrille E, Zimetbaum PJ. Tricuspid valve dysfunction following a pacemaker or cardioverter-defibrillator implantation. J Am Coll Cardiol. 2017 May 9;69(18):2331-2341.
2. Lee TC, Desai B, Glower DD. Results of 141 consecutive minimally invasive tricuspid valve operations: an 11-year experience. Ann Thorac Surg. 2009 Dec;88(6):1845-1850.

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