Tricuspid Valve Patch Augmentation with Annular Detachment in Thin Leaflet Valves

Tricuspid valve leaflet augmentation has been introduced and widely used to overcome the malcoaptation of the tricuspid valve leaflets (1). Many centers have substituted this technique with the recently introduced and more physiologic procedure of “papillary muscle cross control” (2) in patients where malcoaptation is caused by pure tethering leaflets. However, the augmentation technique is still beneficial in a wide variety of pathologies, including the short, small, retracted, or congenitally malformed anterior leaflets.

The leaflet incision in the patch augmentation is conventionally made in the base of the leaflet within a few-millimeter distance from the annulus. However, in some patients with extremely thin and transparent anterior leaflets, cutting and suturing the leaflet in this area may carry a relatively high risk of tearing the leaflet or disrupting the suturing line. Either consequence may result in the recurrence of tricuspid regurgitation.

In this video, a technique of annular detachment—rather than a cusp incision technique—was demonstrated in this subgroup of patients. The technique features augmentation performed at the annular level, where the thin leaflet is left untouched. Annular detachment leaves a substantial bulk of tissue on the leaflet side, effectively allowing for firm and reliable suturing. Next, the annular side is repaired securely during the patch augmentation. Then the annuloplasty ring is placed. The short-, mid-, and long-term results in these patients has confirmed the safety and reliability of the annular detachment technique.

Procedure

The patient is a thirty-seven-year-old woman concerned with dyspnea on exertion. She had no history of previous chest trauma. Echocardiography tests confirmed severe tricuspid valve regurgitation (TR) with right ventricle (RV), right atrium (RA), and annular dilation. Furthermore, malcoaptation of the leaflets mainly caused by shortening and noncompliance of the anterior leaflet was identified. The operative finding was moderate tethering of the septal and posterior leaflet. However, the anterior leaflet was short and thin with ruptured chordae, leaving the anterior half of the leaflet completely unsupported.

Considering the leaflet tissue was insufficient in covering the valve area, it was decided to perform patch augmentation, artificial chordal support, and ring annuloplasty. The annular detachment technique was used for patch augmentation because of the thin onion skin appearance of the basal segment of the anterior leaflet, which prohibited safe cutting and suturing on the leaflet. After annular detachment, a large piece of Matrix PatchTM equine pericardial patch (Auto Tissue Berlin GmbH) was sutured by a CV-5 Gore-Tex suture to repair the leaflet defect. Placement of the annuloplasty ring (32 mm) and chordal support to the flail segment by the “adjustable pericardial lock technique” were followed (3).

Closing Remarks

The immediate postoperative echocardiography showed no TR. In the period following the operation, the patient was completely healthy and asymptomatic in NYHA class I, six years after the operation. Trivial TR confirmed the stability of the repair.

In conclusion, the annular detachment technique can be reliably and safely used in patients who need tricuspid valve patch augmentation, offering a secure and stable line of repair.

References

1. Dreyfus GD, Raja SG, John Chan KM. Tricuspid leaflet augmentation to address severe tethering in functional tricuspid regurgitation. European journal of cardio-thoracic surgery. 2008 Oct 1;34(4):908-10.
2. Amirghofran AA, Nirooei E. Papillary Muscle Cross-Control Technique to Overcome Excessive Leaflet Tethering in Complex Tricuspid Valve Repair. October 2021. doi:10.25373/ctsnet.16873456
3. Amirghofran AA. Adjustable Pericardial Lock Technique for Complex Mitral Valve Repair. October 2019. doi:10.25373/ctsnet.9955976.

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