Outcomes Of Beating-heart Totally Endoscopic Tricuspid Valvuloplasty In Reoperative Cardiac Surgery
Huanlei Huang, Zerui Chen, Huiming Guo, Yingjie Ke, Qingshi Zeng, Biaochuan He, Qian Yan, Jing Liu, Cong Lu, Jingsong Huang, Jimei Chen.
Guangdong General Hospital, Guangzhou, China.
Objectives Conventional median sternotomy reoperation for severe, isolated tricuspid regurgitation after cardiac surgery is associated with high mortality rate, the role of endoscopic surgery treating tricuspid regurgitation following cardiac surgery remains less investigated. This study aims to evaluate the outcomes of a minimally invasive tricuspid valvuloplasty technique treating isolated tricuspid regurgitation following cardiac surgery. Methods Through Jan 2015 to Aug 2018, patients undergoing re-operative tricuspid valve repair (TVP) with totally endoscopic approach were enrolled. A double-lumen endotracheal tube was placed in all patients, a limited 3cm skin incision was applied under the right nipple in men and in inframammary groove in women, the other two separate working-ports were made in the fourth and fifth intercostal space. Cardiopulmonary bypass was established via peripheral vessels, all the procedures were performed on beating heart with normothermic cardiopulmonary bypass. Leaflet patch augmentation and ring implantation were the key techniques for tricuspid valve repair, other repair techniques were also applied as needed. Leaflet patch augmentation technique was considered when there was leaflet retraction with significant reduction of leaflet surface area. Results A total of 51 consecutive adult patients, through Jan 2015 to Aug 2018, with previous cardiac surgery underwent beating-heart minimally invasive endoscopic TVP at our institution. Immediate intraoperative conversion to median sternotomy was required in 3 patient because of unexpected extensive lung adhesions in 2 and difficulty of establishment of peripheral bypass in 1, these patient was excluded from the current study. Hence, 48 patients (mean age 54.7±10.6 years; 11 male) were included into this retrospective analysis. The interval between prior cardiac surgery and current tricuspid repair was 17.6±7.4 years. Thirteen out of 48 patients had previous tricuspid repair concomitant initial cardiac surgery. In the current endoscopic approach, tricuspid repair techniques included annular ring implantation in 45 patients, leaflet augmentation in 40, papillary muscle mobilization in 20, artificial chordae implantation in 8, commissure recreation in 5, cleft closure in 4, edge to edge. The mean CPB time, median ventilation time and median post-operative hospital stay was 136±44.9 min, 20 (range, 5-793) hour and 7 (range, 3-56) day, respectively. The mean volume of chest drainage in the first 24h was 244±218.1ml, there was no exploration for bleeding. One patient underwent re-re-operation due to aortic mechanical prosthesis obstruction 25 days after re-operative TVP. There were only 3 in-hospital deaths. The regurgitant jet area was decreased from 22±9.6 cm2 preoperatively to 3.2±2.9 cm2 postoperatively (P<0.001). All patients were followed-up, the mean follow-up time was 1.3±0.61 years. During follow-up, mild to moderate tricuspid stenosis in 2, recurrent severe regurgitation in 2, one patients died due to right heart failure, no reoperation. Conclusion Outcomes of totally endoscopic tricuspid valvuloplasty with leaflets augmentation for severe isolated tricuspid regurgitation following cardiac surgery are favorable, even in patients with previous tricuspid repair.
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