Tricuspid Valve Replacement Using CorMatrix® Extracellular Matrix Cylindrical Construct

This is the case of a 23-year-old woman with a history of long-term IV drug abuse and tricuspid valve endocarditis. She had a status of post-tricuspid valve replacement seven weeks prior with porcine bioprosthesis, and her history was notable for extensive annular abscess and vegetation burden. She completed six weeks of IV antibiotics and remained sober in a rehab program. She was readmitted with bacteremia and multiple vegetations on the tricuspid bioprosthesis, which was concerning for prosthetic valve endocarditis. Given her improved social situation, medical compliance, and indications for redo surgery, the patient was determined to be an appropriate candidate for reoperation with an extracellular matrix (ECM) valve reconstruction technique after multidisciplinary review.

The patient underwent a preoperative transthoracic echocardiogram (TTE), which demonstrated multiple vegetations on the tricuspid bioprosthesis as well as tricuspid regurgitation (TR). The TTE was also used to measure the tidal volume (TV) annulus for surgical planning. As shown in the video, it was 2.38 cm.

This video demonstrates the back table construction of the ECM TV cylinder valve. In the first frame, a piece of extracellular matrix was measured to the appropriate lengths for constructing the cylinder based on preoperative measurements. The width consisted of the TV annular diameter multiplied by pi. The length was the TV annular diameter multiplied by 1.3. In the second frame, the short edges of the previously cut-to-fit piece of extracellular matrix were secured with double-running layers of 5-0 prolene to form a cylinder. The third frame is a picture of the completed cylinder valve. Additional small extracellular matrix pledgets were also made from remaining matrix.

While the extracellular matrix was constructed on the back table, the patient underwent median sternotomy, bicaval cannulation, and initiation of cardiopulmonary bypass (CPB). A right atriotomy was then performed and the diseased tricuspid valve was explanted. Next, three papillary muscle attachment points were identified approximately 120 degrees apart. The 3-0 prolene suture with extracellular matrix pledgets was then tied down at each selected papillary muscle fixation point, as demonstrated in this video. Next, the constructed extracellular matrix cylinder was brought onto the operative field. The previously tied down 3-0 prolene suture with extracellular matrix pledgets was passed through the distal aspect of the cylinder at three evenly spaced points. The valve apparatus was then lowered into the chest. Next, the three papillary attachment point sutures were tied down to complete the distal fixation of the valve cylinder. Next, three 4-0 prolene sutures with extracellular matrix pledgets were used to secure the proximal edge of the valve apparatus at three equidistant points along the TV annulus. The proximal edge of the valve cylinder was then sutured circumferentially to the annulus in a running fashion. Once the proximal edge was sutured into place, competence of the new cylinder valve was tested with saline.

The patient was successfully weaned from CPB and did well postoperatively. A TTE on postoperative day five demonstrated minimal TR. The patient was eventually discharged home. A TTE 11 weeks postoperatively continued to demonstrate excellent valve performance. The patient continued to do well and returned to school and work.

This video demonstrates successful implantation of an extracellular matrix cylindrical TV construct. The extracellular matrix valve construct resulted in excellent valve performance. To summarize, the size of the extracellular matrix cylinder valve is as follows: width is the TV annular diameter as measured on preoperative imaging multiplied by pi, and the length is the TV annular diameter multiplied by 1.3. Extracellular pledgets were made from extra matrix material and used at all attachment points to enhance tensile strength. Advantages of the extracellular matrix cylinder valve include minimal use of nonbiologic material and the potential for tissue regeneration. Additional research on long-term valve durability is needed.

References

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2. Gerdisch MW, Boyd WD, Harlan JL, Richardson JB Jr, Flack JE III, Palafox BA, et al. Early experience treating tricuspid valve endocarditis with a novel extracellular matrix cylinder reconstruction. J Thorac Cardiovasc Surg. 2014;148(6):3042-3048.
3. Murala JSK, Sassalos P, Owens ST, Ohye RG. Porcine small intestine submucosa cylinder valve for mitral and tricuspid valve replacement. J Thorac Cardiovasc Surg. 2017;154(3j):e57-e59.