Surgical management of tricuspid stenosis

Abstract

Tricuspid valve stenosis (TS) is rare, affecting less than 1% of patients in developed nations and approximately 3% of patients worldwide. Detection requires careful evaluation, as it is almost always associated with left-sided valve lesions that may obscure its significance. Primary TS is most frequently caused by rheumatic valvulitis. Other causes include carcinoid, radiation therapy, infective endocarditis, trauma from endomyocardial biopsy or pacemaker placement, or congenital abnormalities. Surgical management of TS is not commonly addressed in standard cardiac texts but is an important topic for the practicing surgeon. This paper will elucidate the anatomy, pathophysiology, and surgical management of TS.

Keywords: Tricuspid stenosis (TS); tricuspid valve replacement (TVR).

Figure 1

Tricuspid valve. Note the relationship between the anterior, posterior, and septal leaflets; the conduction pathway, and the coronary sinus.

Figure 2

Danger zone for annular sutures. The brackets highlight the area of the tricuspid valve annulus where care should be taken to avoid damaging the atrioventricular node. In this region, the sutures should be passed at the base of the leaflet, avoiding myocardial tissue.

Figure 3

Typical operative set-up for tricuspid valve surgery. Aorto-bicaval cannulation with antegrade plegia line (if necessary) and root vent. Caval snares are placed around the SVC and IVC. IVC, inferior vena cava; SVC, superior vena cava.

Figure 4

Retrograde catheter inserted into the coronary sinus. To help maintain a bloodless field, a retrograde coronary sinus catheter can be inserted, with only its most proximal portion in the sinus.

Figure 5

Right atriotomy. The right atriotomy is made extending from the atrial appendage to the just above the IVC, parallel to the atrio-ventricular groove, leaving at least 2 cm for adequate tension-free closure. IVC, inferior vena cava.

Figure 6

Classic presentation of a stenotic tricuspid valve. Note the thickened leaflets, the fusion of the commissures, and the lack of coaptation.

Figure 7

Tricuspid annulus and intact subvalvular apparatus, after resection of leaflets. Thickened and fused tricuspid leaflets often need to be resected prior to replacing a valve in patients with tricuspid stenosis.

Figure 8

Bioprosthetic tricuspid valve replacement. (A) Non-everting horizontal mattress sutures are placed through the annulus with pledgets on the ventricular side; (B) the sutures are then passed through the sewing ring of the bioprosthetic valve and three tourniquets are used to keep the valve in place as the sutures are tied down. The sutures in the tourniquets are tied last; (C) the valve is seated in the tricuspid annulus. A small dental mirror is used to confirm that the valve is well-seated and the struts are clear of suture material.

Figure 9

Mechanical tricuspid valve replacement. (A) Everting horizontal mattress sutures are placed through the annulus with the pledgets on the atrial side; (B) sutures are then passed through the sewing ring of the mechanical valve. Two tourniquets are used to help seat the valve; (C) the mechanical valve is seated in the tricuspid annulus.