|Year : 2018 | Volume
| Issue : 1 | Page : 59-61
Beating heart tricuspid valve replacement without snugging vena cavae
Anish Gupta1, Velayoudam Devagourou1, Minati Choudhury2, Gaind Saurabh1
1 Department of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, New Delhi, India
2 Department of Cardiac Anaesthesia, All India Institute of Medical Sciences, New Delhi, India
|Date of Web Publication||4-May-2018|
Dr. Anish Gupta
98, Om Vihar Phase-1A Shiv Shankar Road, Uttam Nagar, New Delhi - 110 059
Source of Support: None, Conflict of Interest: None
Tricuspid valve replacement (TVR) is traditionally performed after giving cardioplegia and arresting the heart, but sometimes dense adhesions in redo cases can render looping superior and inferior vena cavae almost impossible. We had a case where the right atrium was hugely dilated and stuck and adhesions were dense, and the condition of the patient was too sick to tolerate myocardial ischemia. We did TVR on a beating heart with femoral and innominate vein cannulation without snugging vena cavae and carefully maintaining a blood level in the right atrium just below tricuspid valve and above the vena caval opening so as to avoid an air lock. It is an innovative technique in a difficult scenario.
Keywords: Beating heart, off-pump, tricuspid valve replacement
|How to cite this article:|
Gupta A, Devagourou V, Choudhury M, Saurabh G. Beating heart tricuspid valve replacement without snugging vena cavae. J Pract Cardiovasc Sci 2018;4:59-61
|How to cite this URL:|
Gupta A, Devagourou V, Choudhury M, Saurabh G. Beating heart tricuspid valve replacement without snugging vena cavae. J Pract Cardiovasc Sci [serial online] 2018 [cited 2023 May 31];4:59-61. Available from: https://www.j-pcs.org/text.asp?2018/4/1/59/231926
| Introduction|| |
Tricuspid valve replacement on the beating heart is well described but requires snugging the vena cavae. We describe a case where the replacement was done without snugging the vena cavae.
| Case Report|| |
A 40-year-old woman who had previously undergone mitral valve replacement (Starr–Edwards ball in cage valve) with repair of tricuspid valve for severe mitral stenosis and tricuspid regurgitation caused by rheumatic heart disease, developed severe recurrent tricuspid regurgitation leading to the right heart failure. The patient had raised jugular venous pressure, massive ascites, [Figure 1] and umbilical hernia preoperatively which was a surgical and anesthetic challenge so and so was optimized with antifailure therapy in the ward for about a week and taken up for surgery. Her chest roentogram showed cardiomegaly with a cardiothoracic ratio of 1:1 and previous ball-in-cage prosthesis in mitral position [Figure 2]. Her electrocardiogram suggested the presence of atrial fibrillation. Mitral valve prosthesis was functioning normally with a peak and the mean gradient of 9 mm hg and 5 mm hg across the mitral valve, respectively. The left ventricular function was around 40%–45%, and there was mild aortic regurgitation as well. There was no evidence of pulmonary artery hypertension or pulmonary regurgitation, and severe low-pressure tricuspid regurgitation was present.
|Figure 2: The chest X-ray showing cardiomegaly and previous ball-in-cage type mitral prosthesis.|
Click here to view
Despite all precautions, the patient fibrillated after induction but was revived immediately and femoral vessels were dissected and looped for emergency cardiopulmonary bypass in case of inadvertent injury during redo sternotomy. Fortunately, redo sternotomy was uneventful; however, there were dense adhesions and mediastinum was frozen, and cannulation strategy was a challenge. Only the aorta could be dissected and was cannulated with 21 french Argyle angled cannula after administrating heparin. The femoral vein was cannulated because superior or inferior vena cave could not be dissected due to dense adhesions, but for drainage of head and neck (superior vena caval territory) innominate vein was cannulated as well because we had to open right atrium; hence, femoral vein cannula cannot drain superior vana cava at that time. Cardiopulmonary bypass (CPB) was instituted, but none of the vena cavae could be mobilized for looping. The right atrium was hugely dilated, and when overlying pericardium was incised, we directly entered the right atrium. Since there is no interatrial or interventricular communication the right heart could be opened without aortic cross-clamp and without fear of cerebral embolism. Pump suckers were put in the right atrium and a level of blood was maintained to avoid sucking of air in venous cannulae and development of air lock [Figure 3]. One assistant was dedicated for suctioning in the right atrium and level was periodically adjusted while taking bites on posterior part of tricuspid valve annulus. Tricuspid valve replacement (TVR) was done using 33 stentless porcine prosthesis under beating heart, and the right atrium was closed. The patient came off bypass easily and postoperative transesophageal echocardiogram revealed normal functioning tricuspid prosthesis without any paravalvular leak. The patient was shifted to the Intensive Care Unit (ICU) on ventilator with inotropic support. The patient was stable hemodynamically, but weaning from mechanical ventilation was difficult due to ascites and ventricular dysfunction. She was tracheostomized, and ascites was tapped multiple times; however, unfortunately, the patient developed ventilator-associated pneumonia, sepsis, acute respiratory distress syndrome, and died of septic shock after prolonged ICU stay.
|Figure 3: Intraoperative image of the blood level below tricuspid valve and above vena cavae.|
Click here to view
| Discussion|| |
TVR is traditionally performed after aortic cross clamping and cardiac arrest which offers a bloodless and motionless field. Using cardiac arrest was not a good option for our patient, as she might not have tolerated any myocardial ischemia due to her sick condition. Many surgeons have described tricuspid valve procedures without CPB to avoid harmful effects of systemic inflammatory response incited by complement cascade and cytokines on septic lungs, especially in the setting of infective endocarditis. Raman et al. described tricuspid valve vegetectomy under vena caval inflow occlusion to avoid harmful effects of CPB in septic lungs; however, occlusion time did not exceed 2 min in any case and tricuspid valve replacement requires longer times. Rim et al. described tricuspid valve replacement using the right heart bypass. Lee et al. described a case of TVR, without using CPB, using a self-made superior and inferior vena cava shunt connected to pulmonary artery; however, it was not possible in our case as there were dense adhesions due to previous surgery and vena cave could not be dissected at all. Another alternative in our case was to use an endoballoon inside vena cavae to improve exposure and to prevent air lock at the same time, but cost and availability remain a concern. Proposed advantages of our technique are avoidance of clamp-induced ischemia and dangerous dissection that can increase postoperative bleeding and reexplorations. However, at the same time, inadvertent air lock in venous line of CPB circuit and difficult exposure remain disadvantages, but surgeon patience and innovative mind are of great importance for patient care.
| Conclusion|| |
Beating heart tricuspid valve surgery avoids myocardial ischemia during aortic cross-clamping and is well-described in literature; however, vena cavae are to be snugged for opening the right atrium. A simple modification in cannulation strategy along with maintaining a blood level in the right atrium to prevent air lock through vena caval openings can rescue the surgeon in densely adhered redo tricuspid operations.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Raman J, Bellomo R, Shah P. Avoiding the pump in tricuspid valve endocarditis – vegetectomy under inflow occlusion. Ann Thorac Cardiovasc Surg 2002;8:350-3.
Rim R. Tricuspid valve replacement using right heart bypass without cardiac and pulmonary ischemia. Tzu Chi Med J 2008;20:318-21.
Lee KK, Yu HY, Chen YS, Chi NH, Chang CI, Wang SS, et al.
Off-pump tricuspid valve replacement for severe infective endocarditis. Ann Thorac Surg 2007;84:309-11.
[Figure 1], [Figure 2], [Figure 3]