Case report
Edge-to-edge repair with ring annuloplasty for post-transplant biopsy-related tricuspid regurgitation
We experienced an early biopsy-related tricuspid regurgitation post-transplant. Transthoracic and transoesophageal echocardiography showed a frail anterior leaflet with a possible ruptured chorda. The tricuspid valve was inspected, and a ruptured chorda was noted in the anterior leaflet with a single torn chorda on the septal leaflet. The corresponding papillary muscle was difficult to identify. The patient underwent successful tricuspid valve repair with edge-to-edge repair and ring annuloplasty. Compared to a complex repair procedure such as the replacement of multiple artificial chordae, the edge-to-edge repair to correct prolapse without creating a gradient across the valve is reproducible
Tricuspid valve regurgitation (TR) is the most common valvular complication following an orthotopic heart transplant (OHT) [1]. The Duke University group reported that 21% of patients had significant TR (moderate or severe TR) when coming off cardiopulmonary bypass, which resolves within 1 year after the transplant, at which point only 6% of these patients have significant TR [2]. Although most cases of TR are asymptomatic, previous studies showed that the presence of intraoperative TR of moderate or greater severity adversely impacts long-term survival [1, 2]. Several mechanisms are responsible for post-transplant TR, including functional TR with or without pulmonary hypertension; geometric distortion of the annulus at the time of implant; endocarditis; and biopsy-related TR [1–3]. Chordal or papillary muscle damage resulting in flail leaflets is the presumed mechanism, and development of tricuspid valve regurgitation has been correlated to the number of biopsies performed [3]. Biopsy-related TR can be diagnosed because the presence of chordal tissue is a well-documented phenomenon [3]. As per Mielniczuk and colleagues, in one series, 47% of patients with new-onset TR had evidence of chordae in their myocardial specimens [3]. Both tricuspid valve (TV) repair and TV replacement are options to fix the pathology [1–3]. Which treatment is the better one is still a matter of debate. We experienced an early biopsy-related TR post-transplant, which underwent successful TV repair using a simple, reproducible technique.
The patient was a sexagenarian male with a past medical history of non-ischaemic cardiomyopathy with an ejection fraction of 15%. The patient initially presented with complaints of worsening exertional dyspnoea and pedal oedema. The patient was on a milrinone drip and underwent a workup for a heart transplant. The patient was supported by an intra-aortic balloon pump and listed for an OHT. He successfully underwent an OHT utilizing a heart from a brain-dead donor. The postoperative course was uneventful, with normal graft function and no TR. No acute rejection was evident from the results of the first heart biopsy. However, he developed severe TR after a second biopsy, with a frail anterior leaflet and a possible ruptured chorda seen on transthoracic and transoesophageal echocardiography (Figure 1). The diagnosis of biopsy-related TR was made and a reoperation was planned.
Figure 1. (A) Preoperative transoesophageal echocardiography showed a frail anterior leaflet and a possible ruptured chorda. (B) Severe tricuspid regurgitation was noted.
1 - Cannulation and exposure of the tricuspid valve (0:13)
A redo median sternotomy was performed. The distal ascending aorta and both venae cavae were cannulated. An inferior vena cava (IVC) cannula was inserted above the IVC anastomosis. The aorta was cross-clamped and antegrade del Nido cardioplegia was administered. The tricuspid valve was exposed via an oblique right atriotomy. A self-retaining retractor was used to expose the valve.
2 - Inspection of the tricuspid valve (1:27)
The torn chordae were observed in the middle of the anterior leaflet. There was another torn chorda on the septal leaflet. It was difficult to identify the corresponding papillary muscle where the ruptured chordae were inserted. A saline test showed regurgitation from the ruptured chordae. The tricuspid annulus was significantly dilated.
3 - Edge-to-edge repair of the tricuspid valve (1:54)
First, an interrupted 4-0 polypropylene suture was placed in the middle of the anterior leaflet and septal leaflet where the ruptured chordae were inserted. The second suture was placed to the right of the first stitch. The saline test administered at this point showed improvement of the prolapse.
4 - Ring annuloplasty (3:17)
Multiple 2-0 braided sutures were placed from the septal leaflet to the anterior leaflet. We typically start an annuloplasty suture from the commissure of the septal leaflet and posterior leaflet in a clockwise manner. Two interrupted sutures were routinely placed on the septal leaflet annulus. The posterior leaflet sutures were then placed counterclockwise to the medial end of the anterior leaflet. A 30-mm semi-rigid annuloplasty ring was implanted.
5 - Final assessment (4:52)
After we implanted the ring, a saline test showed a competent TV without any regurgitation. A single interrupted 5-0 polypropylene suture was added in the middle of the two edge-to-edge repair sutures as a reinforcement.
6 - Intraoperative assessment and outcome (5:12)
The aortic cross-clamp time was 40 minutes, and the cardiopulmonary bypass time was 66 minutes. The patient was successfully weaned off cardiopulmonary bypass without any complications. Postoperative transoesophageal echocardiography revealed no TR, with a mean gradient of 1 mmHg (Figure 2).
Figure 2. (A) Preoperative transoesophageal echocardiography showed no tricuspid regurgitation. (B) The mean transvalvular gradient was 1 mmHg.
In a patient with ruptured chordae of the tricuspid valve, both TV repair and TV replacement are treatment options [1]. For TV repair, replacement of chordae using artificial chordae has been reported [4]. Eishi and colleagues reported the new concept of TV repair called ‘spiral suspension,’ which involves relocation of the papillary muscles [5]. Both techniques require identification of the papillary muscles, proper placement of stitches and adjustment of the length of the polytetrafluoroethylene sutures based on saline test results, which may be technically challenging. Alfieri and colleagues reported the innovative concept of edge-to-edge repair including the ’clover technique’ in tricuspid valve repair with favourable long-term results [6].
A major advantage of this technique is that it is reproducible, simple and not time consuming compared to the complex subvalvular procedure. This reproducible outcome with long-term durability [6] was also supported by the study results of Lee and colleagues [7]. A potential downside of this technique can be creating the gradient across the tricuspid valve after the edge-to-edge repair and annuloplasty; however, in the present case, the mean gradient was 1 mmHg, which was similar to that in the report by Lee and colleagues. TV replacement may be more definitive but there is a risk of infection, especially in the setting of immunosuppression therapy post-transplant, iatrogenic atrioventricular block from replacement stitches and the prosthesis itself and a potential reoperation due to structural valve deterioration during the follow-up period [1].
Some surgeons routinely perform DeVega annuloplasty in patients who have received a transplant [1]. In the present case, we performed ring annuloplasty because the TV annulus was already dilated, likely due to days of severe TR after the biopsy. Transcatheter edge-to-edge repair is commercially available in Europe and North America. Puscas and colleagues reported a successful percutaneous edge-to-edge repair for severe TR after a heart transplant. In our institute, transcatheter edge-to-edge repair has not yet been performed. Although this approach may have the potential to correct significant TR post-transplant as a less invasive procedure, further evidence is warranted. In the present case, severe TR occurred in the early post-transplant period so that dissection was less challenging. Furthermore, one of the benefits of open surgery was to address annular dilatation by annuloplasty. In the present case, the repair was performed with aortic cross-clamping. Tricuspid surgery can be performed technically with a beating heart. We preferred to arrest the heart because there was a possibility of placing an artificial chorda, which needs a precise procedure under cardioplegic arrest.
In conclusion, we experienced biopsy-related TR as an early post-transplant complication. Successful TV repair was performed utilizing the edge-to-edge repair with concomitant ring annuloplasty.
Case Report Follow-up
The patient continued to do well during the follow-up period.
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PubMed Abstract | Publisher Full Text
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3, Mielniczuk L, Haddad H, Davies RA, Veinot JP. Tricuspid valve chordal tissue in endomyocardial biopsy specimens of patients with significant tricuspid regurgitation. J Heart Lung Transplant 2005;24:1586–90.
PubMed Abstract | Publisher Full Text
4. Huang Y, Dearani JA, Stephens EH, Saran N, Miranda WR, Taggart NW et al. Outcomes of Tricuspid Valve Repair With Artificial Neochordae in Pediatric and Adult Patients. Ann Thorac Surg 2022;114:826–32.
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PubMed Abstract | Publisher Full Text
6. Lapenna E, Gramegna F, Del Forno B, Scarale MG, Nonis A, Carino D et al. Long-term Results of Clover and Edge-to-Edge Leaflet Repair for Complex Tricuspid Regurgitation. Ann Thorac Surg 2024;118:1072–9.
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7. Lee H, Kim J, Oh SS, Yoo JS. Long-term Clinical and Hemodynamic Outcomes of Edge-to-Edge Repair for Tricuspid Regurgitation. Ann Thorac Surg 2021;112:803–8.
PubMed Abstract | Publisher Full Text
8. Sorajja P, Whisenant B, Hamid N, Naik H, Makkar R, Tadros P et al. Transcatheter Repair for Patients with Tricuspid Regurgitation. N Engl J Med 2023;388:1833–42.
PubMed Abstract | Publisher Full Text
9. Puscas T, Gautier CH, Martin AC, Pechmajou L, Du Puy-Montbrun L, Caudron J et al. Transcatheter Tricuspid Repair for Tricuspid Regurgitation After Heart Transplantation. JACC Case Rep 2023 12:101767.
Authors
Sooyun Caroline Tavolacci, Corazon de la Pena & Suguru Ohira
Affiliation
Westchester Medical Center, Valhalla, NY, USA
Corresponding Author
Suguru Ohira
Westchester Medical Center
Valhalla
NY
USA
Email: suguru.ohira@wmchealth.org
© The Author 2025. Published by MMCTS on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
