Eur J Cardiothorac Surg 2002;21:763-764
© 2002 Elsevier Science NL
Tricuspid bioprosthesis replacement with cryopreserved mitral homograft
J.M. Grinda*,
R. Zegdi,
R. Leroux,
A. Deloche
Department of Cardiac Surgery, Hôpital Européen Georges Pompidou (HEGP), 21 rue Leblanc, 75908 Paris Cedex 15, France
Received 28 October 2001;
received in revised form 18 December 2001;
accepted 3 January 2002.
* Corresponding author. Tel.: +33-1-5609-3624; fax: +33-1-5609-2219
e-mail: jean-michel.grinda{at}egp.ap-hop-paris.fr
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Abstract
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We report the case of replacement of a dysfunctional tricuspid Hancock bioprosthesis by a cryopreserved mitral homograft. Tricuspid bioprosthesis was approached on a beating heart. The mitral homograft was orientated so as the anatomic anterior leaflets corresponding and a semi rigid prosthetic ring was inserted. At 1 year follow-up, the patient's clinical condition and echocardiographic results were satisfactory.
Key Words: Valvular surgery • Tricuspid valve disease • Valvular homograft
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1. Introduction
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Because of poor long-term results, debate is still continuing concerning the choice of prosthesis for tricuspid valve replacement. Mitral valve homograft has been used in patients with tricuspid bacterial endocarditis [1–5] and should represent an interesting valvular substitute in cases of redo tricuspid prosthesis replacement for the haemodynamic performances and low thrombogenicity rate.
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2. Case report
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A 39-year-old woman was referred in December 2000 because of tricuspid bioprosthesis Hancock deterioration. Twenty years ago, she was operated on for agenesis of tricuspid valve and atrial septal defect. She had a long history of tricuspid valve dysfunction. On examination, she showed signs of significant congestive right cardiac failure with jugular distension, hepatic congestion with low extremity oedema and ascites. ECG showed right atrial hypertrophy with right heart bundle branch block and atrial fibrillation. Transoesophageal echocardiogram (TEE) with colour Doppler studies showed dilated right cardiac chambers with massive bioprosthesis regurgitation and restriction, with a mean transvalvular gradient of 7 mmHg. The right ventricular shortening fraction was 36%. We decided to implant a mitral homograft (Fig. 1)
instead of the Hancock bioprosthesis.
The operation was performed with cardiopulmonary bypass. The tricuspid valve was approached via the right atrium on a beating heart (Fig. 2)
. The Hancock bioprosthesis was found to be calcified with three-fixed leaflet but no tear. The Hancock bioprosthesis was removed. The mitral homograft (from the Tissue Bank of the Assistance Publique de Paris, Hôpital Saint Louis) was thawed, rinsed, and trimmed of excess annular tissue and fat and the excess ventricular wall from papillary muscles. The mitral homograft was oriented so that the anterior mitral leaflet was set along the anterior part of the tricuspid annulus. The anterior papillary muscle was divided into two parts according to chordae distribution. The anterior tip was attached to the septo-marginal trabecula and the posterior to the interventricular septum avoiding conduction tissue. The posterior papillary muscle was attached to the free wall of the right ventricle. Location of attachment on the septum, the septo-marginal trabecula and the right ventricular free wall were determined to provide an adequate length to the reimplanted papillary muscle avoiding both leaflet prolapse or retraction. Papillary muscles attachment was performed using three 4/0 prolene stitches pledgeted with native pericardium for each muscle. With the subvalvular apparatus secured, a running Prolene 4/0 suture was used to sew the homograft mitral annulus into the tricuspid orifice. A tricuspid Carpentier Prosthetic Ring (size 36 mm diameter) was inserted. Following discontinuation of cardiopulmonary bypass, intraoperative TEE showed satisfactory functional results, with 2 mmHg transvalvular gradient. Because of alteration of right ventricular function, the patient was taken to the intensive care unit and given adrenaline for 3 days. One year later, the patient was asymptomatic. TEE showed satisfactory mitral homograft function, with a trivial residual leak and no significant gradient (with 2 mmHg transvalvular gradient).
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3. Discussion
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The advantages of the homograft include good haemodynamic performance, low thrombogenicity rate and low reinfection rate in case of active bacterial endocarditis. Because of these advantages, mitral homografts could be considered as an interesting alternative procedure for prosthetic valve replacement when the gold standard tricuspid repair is not feasible. In right-sided endocarditis, because of the lack of available clean tissue and to avoid prosthesis implantation, total or partial replacement of the tricuspid valve by a mitral homograft have been proposed and have provided satisfactory results [1–4]. Replacement of dysfunctional tricuspid prosthesis should represent a good indication for a mitral homograft use.
There are still controversies about the technical aspects of homograft replacement of the tricuspid valve [1,3,4]. Most of the previously reported cases of mitral homograft replacement for bacterial tricuspid endocarditis have been performed with cardioplegic arrest [1,3,4,5]. We have found no major technical difficulty with the beating heart technique that we usually use for tricuspid procedure. The beating heart technique provides the best myocardial protection, and this was particularly interesting in such a case with a long history of tricuspid prosthesis dysfunction. Different orientations of the homograft within the tricuspid orifice have been proposed. Acar and colleagues [3] oriented the mitral homograft within the tricuspid orifice so that the anterior leaflet was in relationship to the septum. Pomar and colleagues [1] have oriented the mitral homograft according to its orientation within the left ventricle, i.e. the anterior leaflet anteriorly and the posterior leaflet posteriorly. We have chosen this technique but divide the anterior papillary muscle to avoid the risk of ventricular outflow tract obstruction that can be encountered with reimplantation of the anterior papillary muscle on the septum. Papillary muscle attachment was performed using native pericardium pledgeted stitches without performing a trans-mural fixation technique. We did not use polytetrafluoroethylene to reinforce papillary muscle anchorage or to support excessive chord traction. The previously reported cases of mitral homograft replacement for bacterial tricuspid endocarditis have usually been achieved without prosthetic ring implantation [1,4,5]. To secure the homograft implantation we have chosen to implant a tricuspid prosthetic ring. In this indication of prosthesis replacement in a non infected area we were not reluctant to implant a prosthetic ring. A prosthetic ring decreases tension on the annular homograft attachment and also on the chordal and papillary muscle attachment.
Mitral homograft replacement is a promising technique for tricuspid procedure when tricuspid repair is not achievable. Long-term follow-up is obviously needed to ascertain clinical and hemodynamic results.
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References
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Pomar J., Mestres C., Pare J-C., Miro J. Management of persistent tricuspid endocarditis with transplantation of cryopreserved mitral homografts. J Thorac Cardiovasc Surg 1994;107:1460-1463.[Abstract/Free Full Text]
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Mestres C-A., Miro J., Pare J-C., Pomar J. Six-year experience with cryopreserved mitral homografts in the treatment of tricuspid valve endocarditis in HIV-infected drug addicts. J Heart Valve Dis 1999;8:575-577.[Medline]
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Acar C., Iung B., Cormier B., Grare P., Berrebi A., D'Attellis N., Acar J., Carpentier A. Double mitral homograft for recurrent bacterial endocarditis of the mitral and the tricuspid valves. J Heart Valve Dis 1994;3:470-472.[Medline]
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Katsumata T., Westaby S. Mitral homograft replacement of the tricuspid valve for endocarditis. Ann Thorac Surg 1997;63:1480-1482.[Abstract/Free Full Text]
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Hvass U., Lansac E., Chatel D., Henri I. Mitral homograft for tricuspid valve endocarditis complicating a congenital fistula between the right coronary artery and right ventricle. J Heart Valve Dis 1996;5:564-566.[Medline]
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Abstract
1. Introduction
