Absence of posterior tricuspid valve leaflet and valve reconstruction

Abstract

We report a rare case of the absence of a posterior tricuspid valve leaflet. A male patient, aged 46, suffering from severe tricuspid valve regurgitation (TR) of unknown aetiology and atrial septal aneurysm was referred to our hospital for surgery. On surgical inspection, the posterior tricuspid valve leaflet and its subvalvular apparatus were completely absent and only the valve annulus was seen in the corresponding position. The anterior and septal leaflets were normal. We successfully reconstructed the tricuspid valve as follows: the head of an anterior papillary muscle was approximated to the ventricular septum (Sebening stitch). After the approximation of the centre of the tricuspid annulus of the anterior leaflet to the tricuspid annulus on the opposite side, a sizer of 29 mm in diameter was easily passed through the anterior orifice. The posterior orifice was closed with running sutures (posterior annulorrhaphy after Hetzer). Before these procedures, we attempted to reconstruct the tricuspid valve with a posterior annulorrhaphy alone; however, valve competence was insufficient. A Sebening stitch was necessary to improve the valve competence. Echocardiography showed TR grade 1 at the patient's discharge from hospital and TR grade 1 to 2 at the follow-up, 10 months after the operation.

Figure 1:

Intraoperative pictures of the tricuspid valve. (A) The tricuspid valve before valve reconstruction (surgeon's view). The posterior valve leaflet and subvalvular apparatus were absent and only the valve annulus is seen. A: anterior leaflet; S: septal leaflet. (B–E) Placing a Sebening stitch (surgeon's view). Placing a pledgeted mattress suture passing through the head of an anterior papillary muscle (B). Tying-down of the suture (C). Placing the same suture further on the wall of the ventricular septum on the opposite site (D). Tying-down of the suture (E).

Figure 2:

Posterior annulorrhaphy after Hetzer (surgeon's view). (A) Approximation of the centre of the tricuspid annulus with pledgeted mattress sutures to generate anterior and posterior orifices. (B) The posterior orifice is closed with running sutures. (C) Good valve competency was demonstrated by the saline test after the tricuspid valve repair. The reconstructed tricuspid valve functioned as a monocusp valve consisting of the anterior leaflet.

Supplementary Video 1: Echocardiography 10 months after the tricuspid repair shows grade 1 to 2 tricuspid valve regurgitation (performed by Dr Michael Grafe, Deutsches Herzzentrum Berlin, Berlin, Germany).