Asian Cardiovasc Thorac Ann 2005;13:238-240
© 2005 Asia Publishing EXchange Ltd
Correction of Traumatic Tricuspid Insufficiency Using the Double Orifice Technique
Guo-Hua Luo, MD,
Wei-Guo Ma, MD,
Han-Song Sun, MD,
Jian-Ping Xu, MD,
Li-Zhong Sun, MD,
Sheng-Shou Hu, MD
Department of Cardiac Surgery, Fu Wai Hospital, Chinese Academy of Medical Sciences, Beijing, China
For reprint information contact: Wei-Guo Ma, MD Tel: 86 10 6831 4466 ext 8240 Fax: 86 10 6831 3012 Email: wgma{at}yahoo.com, Department of Cardiac Surgery, Fu Wai Hospital, 167 Northern Lishi Road, Beijing 100037, China.
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ABSTRACT
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Traumatic tricuspid insufficiency is an uncommon clinical condition and surgical procedures vary. In this paper we report our experience in treating traumatic tricuspid insufficiency using the double orifice technique. From January 2000 to September 2003, 10 patients with traumatic tricuspid regurgitation were admitted to our hospital, 5 of whom were corrected using the double orifice technique. There were 4 males and 1 female with ages ranging from 31 to 52 years. Preoperative transthoracic echocardiography (TTE) detected severe tricuspid regurgitation in 4 patients and moderate tricuspid regurgitation in 1 patient. At surgery, tear of the tricuspid anterior papillary muscle was found in 2 cases and anterior chordal rupture in 3 cases. The valves were successfully repaired using the double orifice technique in combination with ring annuloplasty. There was no repeat operation, no operative complications or deaths. Before discharge, TTE detected normal tricuspid valve function in 2 cases and tiny regurgitation in 3 cases. After a follow up of 8 to 36 months, TTE demonstrated normal valve function in 1 patient and tiny regurgitation in 4 patients. The double orifice technique appears to be a simple but effective method of repairing traumatic tricuspid incompetence. Satisfactory clinical outcomes can be produced in carefully selected patients.
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INTRODUCTION
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Traumatic tricuspid regurgitation is a relatively rare disease. It is often well tolerated for a long time because of the lower pressure in the right heart, and some patients are asymptomatic and remain undiagnosed. Recently, earlier diagnosis has become more common due to the wider application of transthoracic echocardiography (TTE) in the evaluation of blunt chest trauma. A variety of attempts to repair traumatic tricuspid insufficiency have been reported, such as reconstruction of the chordae and papillary muscle by using native pericardium or synthetic materials, chordal transfer techniques, plication of leaflet and annuloplasty.1 In this paper we report our experience of correcting traumatic tricuspid insufficiency in 5 patients with the double orifice technique.
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PATIENTS AND METHODS
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Between January 2000 and September 2003, there were 10 patients with traumatic tricuspid regurgitation necessitating surgical treatment in our hospital, 5 of whom were corrected using the double orifice technique. There were 4 males and 1 female in this group with a mean age of 39.3 ± 7.8 years (31 to 52 years). Their mean body weight was 63.9 ± 7.4 kilograms (56 to 75 kg). Traumatic tricuspid regurgitation was attributed to blunt chest trauma caused by traffic accidents in 4 cases and to a strike on the chest by a heavy object in the remaining 1 patient.
Symptoms included exertional palpitations and dyspnea. Systolic murmur heard best at the left lower parasternal edge was present in all five patients. The mean duration between injury and tricuspid operation was 31.0 ± 31.7 months (6 to 84 months). The cardiothoracic ratio ranged from 0.42 to 0.60 (mean 0.50 ± 0.06). Electrocardiogram disclosed incomplete right bundle branch block in 3 patients, atrial fibrillation in 1 patient, and enlargement of the right atrium and ventricle in 1 patient. TTE detected severe tricuspid regurgitation in 4 patients and moderate tricuspid regurgitation in 1 patient, who suffered concomitant traumatic mitral regurgitation.
The repair of tricuspid incompetence was performed under cardiopulmonary bypass (CPB) with the aorta clamped. The average time of CPB was 89.3 ± 19.8 minutes (60 to 112 min), and the mean aorta-clamping time was 52.0 ± 12.0 minutes (34 to 71 min). The competence of the tricuspid leaflet was tested by injecting electrolyte solution through a catheter into the right ventricle, and the results of repair were determined by transesophageal echocardiography (TEE) after weaning from CPB. At surgery, tear of the tricuspid anterior papillary muscle was seen in 2 cases, and anterior chordal rupture was seen in 3 cases. Mitral valvuloplasty was performed in 1 patient, which was complicated by traumatic mitral posterior leaflet prolapse with severe regurgitation. The valvuloplasty included rectangular resection of the posterior leaflet of the mitral valve, with repair of the leaflet using running sutures, complemented by insertion of an annuloplasty ring.
In patients with a torn anterior papillary muscle, a double-needle 4/0 Prolene suture (Ethicon, Somerville, NJ, USA) with a Teflon felt pledget was first placed in situ to secure the tear of the anterior papillary muscle, then the "double orifice technique" was employed by placing 2 stitches of double-needle Prolene sutures from the edge of the anterior leaflet to the edge of the septal leaflet, thus forming 2 orifices of identical size. In patients with ruptured anterior chordae tendineae, the anterior leaflet was sutured to the septal leaflet in an edge-to-edge fashion by using the same method to form 2 orifices with different sizes. After completing the procedure above, a Carpentier-Edwards tricuspid annuloplasty ring (Baxter International Inc, Irvine, CA, USA) was implanted in 4 cases and the De Vega annuloplasty using a double-needle pledgeted 3/0 Prolene suture was performed in 1 case.
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RESULTS
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Postoperative TEE demonstrated no tricuspid stenosis or residual regurgitation in all cases. There were no cases of repeat operation and no operative deaths. Before discharge, TTE detected normal tricuspid valve function in 2 cases and tiny regurgitation in 3 cases whilst revealing no evidence of stenosis. After 8 to 36 months postoperatively, repeat TTE demonstrated normal valve function in 1 patient and tiny regurgitation in 4 patients.
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DISCUSSION
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Traumatic tricuspid valve incompetence is an uncommon clinical condition. Common causes are anterior papillary muscle tear or anterior chordal rupture due to blunt chest trauma. In clinical circumstances, traumatic tricuspid regurgitation should be highly suspected in patients with a history of chest injury who present with palpitations and dyspnea and have EKG signs of incomplete or complete right branch bundle block.1 TTE can not only confirm the diagnosis, but also visualize the torn anterior papillary muscle or chordae in some cases, providing evidence in making operative decisions.
In the literature, there are many reports focused on the use of tricuspid valve replacement to treat traumatic tricuspid incompetence.2 Employment of synthetic materials to replace the ruptured chordal or papillary muscle and chordal transfer techniques have also been described.1,3 Enlightened by Alfieri’s experience of using the double orifice as a method for correcting significant anterior leaflet prolapse in mitral valve repair surgery,3 we have applied the double orifice technique in the treatment of traumatic tricuspid regurgitation. However, there are always residual regurgitations at the valve commissures after the anterior and septal leaflets are sewn in an edge-to-edge fashion. The reduction of annular size by employing the annuloplasty ring or De Vega annuloplasty increased the area of leaflet coaptation and promoted full valve competency.4
The double orifice technique is more suitable for patients with anterior leaflet prolapse of the tricuspid valve, with apparent dilation of the tricuspid annulus. In some patients, the results of surgical repair by methods other than the double orifice technique might not be satisfactory. Traditionally in such circumstances, surgical intervention consisted of tricuspid valve replacement if the double orifice technique was not employed.
In comparison to tricuspid valve replacement as a treatment for traumatic tricuspid incompetence, tricuspid valve repair should be the treatment of choice as it avoids complications inherent in prosthetic heart valves.2 In selected patients, repair by the double orifice technique can achieve satisfactory clinical results and avoid the use of tricuspid valve replacements.
In conclusion, we believe the double orifice technique is a technically simple but effective method for repairing traumatic tricuspid incompetence. Careful selection of operative indications will produce satisfactory clinical outcomes.
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REFERENCES
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- Dounis G, Matsakas E, Poularas J, Papakonstantinou K, Kalogeromitros A, Karabinis A. Traumatic tricuspid insufficiency: a case report with a review of the literature. Eur J Emerg Med 2002;9:258–61.[Medline]
- van Son JA, Danielson GK, Schaff HV, Miller FA Jr. Traumatic tricuspid valve insufficiency. Experience in thirteen patients. J Thorac Cardiovasc Surg 1994;108:893–8.[Abstract/Free Full Text]
- Alfieri O, De Bonis M, Lapenna E, Agricola E, Quarti A, Maisano F. The "clover technique" as a novel approach for correction of post-traumatic tricuspid regurgitation. J Thorac Cardiovasc Surg 2003;126:75–9.[Abstract/Free Full Text]
- Moainie SL, Guy TS, Plappert T, Gorman JH 3rd, Gorman RC. Correction of traumatic tricuspid regurgitation using the double orifice technique. Ann Thorac Surg 2002;73:963–5.[Abstract/Free Full Text]
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Valve repair for traumatic tricuspid regurgitation
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[Abstract]
[Full Text]
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ABSTRACT
INTRODUCTION
