Tricuspid Valve Repair in Patient With Hypoplastic Left Heart

By Ikenna Omeje, MD, Georgi Christov, MD, Orsolya Friedrich, MD, and Martin Kostolny, MD

Tricuspid valve regurgitation is not uncommon in patients with hypoplastic left heart syndrome and has been shown to be a significant factor affecting the success of staged surgical palliation in these patients. We present a video showing tricuspid valve repair in an eleven month old male infant with hypoplastic left heart syndrome following the Norwood stage1 palliation and the bidirectional cavo-pulmonary (Glenn) anastomosis.

Preoperative echocardiogram demonstrated significant (moderate to severe) tricuspid valve regurgitation due to incomplete coaptation of the septal and posterior leaflets, thickened and retracted edges of the leaflets and a dilated valve annulus.

The film is shown from the operating surgeon's view. Surgery was performed on cardiopulmonary by-pass using standard aortic and bicaval cannulation. Following cardioplegia, the right atrium was incised and retracted with sutures. The tricuspid valve was assessed. The edges of the septal and inferior leaflets were rolled inward and the chords appeared elongated. The valve annulus was dilated and on water testing, there was obvious prolapse of the leaflets into the atrium. Much of the regurgitation was found to be through the zone of incomplete coaptation of the septal and posterior leaflets.

The septal and posterior leaflets were sutured edge-to-edge with interrupted 5-0 surgilene sutures, thus creating a bicuspid valve. Further testing showed a small regurgitant jet through the antero-septal commissure, which was subsequently addressed by placing additional sutures in the commissure. Finally, plication plasty (De Vega) of the annulus was performed using a 3-0 prolene suture with pledgets. The suture was tied with an olive dilator positioned in the valve in order to achieve the desired size of the annulus. Final testing showed full valve competence. The right atriotomy was closed in two layers and the patient was uneventfully weaned from bypass.

Postoperative echocardiogram showed trivial tricuspid valve regurgitation, no tricuspid valve stenosis and good right ventricular function. The child was discharged home 4 days after surgery.