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Minimally Invasive Cone Repair
mugisha kyaruzi, Gokalp Altun;
Istanbul Aydin University Florya Medical Park Hospital, istanbul, Turkey
BACKGROUND:A 26 years old female was presented to us with dyspnea and fatigue that has prolonged for one year. Physical examination revealed no significant signs of cardiac manifestation. Transthoracic echocardiogram and transesophageal echocardiogram revealed ebstein anomaly with severe tricuspid regurgitation. Our patient was reffered for and surgical repair of tricuspid valve which was performed via minimally invasive right anterolateral minithoracotomy. Postoperative echocardiogram revealed mild tricuspid regurgiation with good coaptation of leaflet and mild tricuspid stenosis. Postoperative period was uneventiful and patient was discharged on postoperative day 4.
METHODS:A 26 yeaars old female was presented to our cardiology department with dyspnea and fatigue that has prolonged for one year. Physical examination revealed parasternal systolic murmur. Chest X-ray showed a moderate cardiomegaly, narrow waist and increased cardiothoracic ratio(
Figure 1). ECG showed normal sinus rhythm.Both transthoracic and transesophageal echocardiogram(TTE,TOE) revealed ebstein anomaly with severe tricuspid regurgitation(
video 2,preop).Magnetic resonance imaging(MRI) revealed a normal ejection fraction of both chambers and ebstein anomaly with severe tricuspid regurgitation. She was reffered for surgery to our department. Under general anesthesia a a patient was supine positioned with the right chest elevated and double lumen intubation was performed(
Figure 2). A 5-6cm anterolateral minithoracotomy incision through 4th intercostal space(ICS) was performed. Peripheral cannulation through right femoral artery(19F) and right femoral vein(23F) with right internal juguler(17F) vein was performed to initiate cardiopulmonary bypass (CPB). Pericardium was opened 2cm above the phrenic nerve and suspended. Chitwood aortic cross clamp was placed through the 2nd intercostal space whereby both pulmonary artery and ascending aorta were cross clamped and isothermic cold blood cardioplegia was delivered to arrest the heart. Right atriotomy was performed to expose the tricuspid valve. Firstly anterior leaflet was resected from the tricuspid valve annulus,then septal leaflet was delaminated from ventricular wall and mobilized, anterior leaflet was likewise delaminated from ventricular wall and mobilized. Anterior leaflet and septal leaflet were joined together with 6,0 prolene to create a cone with sufficient orifice.The atrialized part of right ventricle was plicated with double layer by using 4,0 prolene. During plication care was taken not to damage the branches of right coronary artery by not taking deep bites and avoid kinking of right coronary artery. The true tricuspid annulus was diminished with pledged 4,0 prolene sutures. The mobilized leaflets were attached to the true annulus with the aid of 5,0 prolene taking care not to damage a conduction system. A water saline test was performed and tricuspid valve was found to be competent with minor regurgitation. Atriotomy was closed in double layer. A cross clamp was released and the heart started beating spontaneous in sinus rhythm. Postoperative TOE revealed a well functioning and coaptating tricuspid valve with trace regurgitation and maximum gradient of 5mmHg. Cross clamping time was 133 minutes and CPB time was 210 minutes. CPB was terminated, a chest tube was placed in position and our patient was sent to intensive care unit for further follow up. Postoperative period was uneventiful and our patient was discharged on postoperative day 4. Postoperative one month follow up, TTE revealed a well functioning tricuspid valve with minor regurgitation and normal heart chambers (
video 2-postop 1st month).
CONCLUSIONS:Ebstein anomaly surgical repair via minimally invasive right lateral minithoracotomy can be performed with satisfactory postoperative results. We believe that minimally invasive tricuspid valve surgery can be routinely performed in selected patients as routinely done in mitral valve surgery.
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