Antonios Pitsis, Pitsis, Antonios, Tsotsolis, Nikolaos, Nikoloudakis, Nikolaos, Economopoulos, Vasilios, Kelpis, Timotheos, Keremidis, Isaak, Boudoulas, Harisios, Boudoulas, Konstantinos Dean

Redo isolated tricuspid repair following previous mitral valve replacement carries a high mortality and morbidity. The authors’ totally endoscopic technique avoids entirely heart dissection, thus minimizing surgical trauma and possibly reducing morbidity and mortality. The authors present a surgical repair performed for a 70-year-old man with severe tricuspid regurgitation (TR) who was heavily symptomatic in class III, with a history of a mitral valve replacement for rheumatic disease with a Bjork Shiley tilting disk valve in 1989 and a EuroSCORE 2 of 5.99. On transesophageal echocardiogram (TEE), apart from the grade 4 TR there was a dilated tricuspid annulus at 45 mm in the 4-chamber view.The operation was performed through a periareolar 3 cm working incision. The authors entered the right chest through the fourth intercostal space, and the extra small Alexis wound protector was utilized. The 3D 30-degree Karl Storz endoscope was inserted through the same intercostal space in the anterior axillary line. CO2 was inflated into the right chest through then same port. Cardiopulmonary bypass (CPB) was established by using a 25 Fr femoral and an 18 Fr jugular venous cannula, and an 18 Fr arterial femoral cannula, together with vacuum assist.On full CPB the authors entered the right atrium (RA)—en block with the pericardium—at a safe distance below the atrioventricular groove, without any intrapericardial dissection or snaring of the superior or inferior vena cava. The CPB technician was carefully adjusting the vacuum assist in order to avoid an air lock of the circuit. With the use of the LigaSure™ bipolar diathermy, the authors performed an almost 10 cm horizontal incision, and the tricuspid valve became immediately exposed. They used one pericardio-atrial stay suture in the middle of the top part of the incision to lift the roof of the RA and expose the tricuspid valve.On valve examination, apart from the annular dilatation, they saw extensive fibrosis mainly of the posterior leaflet and less fibrosis of the anterior leaflet. Also, there was some gapping of the anteroposterior commissure. The septal leaflet appeared normal.The authors performed a closure of the anteroposterior commissure with three polytetrafluoroethylene 3/0 sutures, creating a bicuspid valve with an anteroposterior and a septal leaflet. They concluded the repair by performing an annuloplasty using a custom-made band made out of a folded Dacron strip and titanium clips placed 1 cm apart. The annuloplasty sutures were secured over the custom-made "personalized ring" with the Core-Knot device.A water test was performed and seemed satisfactory prior to the closure of the atriotomy with a running Prolene® 3/0 suture. Postoperative TEE revealed a well-functioning tricuspid valve without any regurgitation or stenosis. The CPB time was 75 min. The patient was extubated a few hours later and had an uneventful recovery.The authors’ approach is quite minimalistic (no heart dissection at all) and at the same time offers an excellent exposure of the tricuspid valve. The closure of the anteroposterior commissure is another key point of this technique and they believe that it helps to avoid TR recurrence.Additional ReferencesPitsis A, Nikoloudakis N, Tsotsolis N, et al. Totally endoscopic bileaflet mitral valve repair with preformed chordae loops. CTSNet, Inc: Chicago, IL. Published March 19, 2019. Accessed May 22, 2019. doi:10.25373/ctsnet.7837853.