Case Report

A 34 - year- old female was admitted to our hospital with exertional dyspnea. Meanwhile, she was suffering from increasing pretibial pitting edema. Her past medical history possessed a mitral valve replacement (with 27 mm Carbomedics mechanical valve) and left auriculopexy with tricuspid valve open commissurotomy at another clinic 9 years ago. Her transthoracic echocardiographic examination revealed severe tricuspid valve regurgitation, mild aortic valve regurgitation, an ejection fraction of 60%, mean pulmonary arterial pressure of 25 mm Hg, normofunctional mechanical valve in mitral position and right atrial (58 mm) and right ventricular (45 mm) dilatation. Her abdominal ultrasound showed hepatomegaly of 20 cm in transverse long axis, coarse granulation of liver parenchyme, diffuse ascites within abdominal cavity, and severe dilation of hepatic veins and inferior vena cava. Right cardiac catheterization measured an increased right atrial pressure of 14 mm Hg (Figure 1).

Figure 1

Figure 1

She was operated under endotracheal general anesthesia and in supine position. Constricting layers of epicardium were separated if possible. We freed the pericardium in this order: first from the aorta and pulmonary artery, including the left ventricular outflow tract; then from the left and right ventricles and the left pulmonary vein orifices; and finally from the superior and inferior venae cavae. After heparinization, extra-corporeal circulation was established between the venae cavae and the ascending aorta. Right atriotomy was performed on the beating heart supported by total cardiopulmonary bypass. The entire valvular apparatus was carefully examined in order to assess the feasibility of reconstructive surgery and to plan the operative technique. Severe tricuspid regurgitation was evident (Figure 2).

Figure 2

Figure 2

Posterior and anterior commissures were repaired primarily by 5/0 polypropylene suture material (Figure3).

Figure 3

Figure 3

After this tricuspid valve re-repair, a 30 mm Kalangos Biodegradable Tricuspid Ring (Kalangos Biodegradable Tricuspid Ring, Bioring SA, Lonay, Switzerland,TRK 30A) was inserted for annuloplasty (Figures 4&5).

Figure 4

Figure 4

Figure 5

Figure 5

Incision of right atriotomy was closed. The post-operative course was uneventful with successful correction.. Postoperative echocardiographic data confirmed complete relief of the tricuspid regurgitation and showed a reduction of the right atrial diameter.

Comments

Moderate-to-severe functional tricuspid regurgitation (TR) should be corrected in patients undergoing surgery for left-sided valvular diseases, to improve long-term outcomes(₁). Tricuspid valve replacement is associated with a nonnegligible complication rate because of specific disadvantages of mechanical or biologic prostheses(₂). Several techniques of surgical repair (suture annuloplasty or prosthetic annuloplasty) to correct this condition have been described. Multiple clinical studies have shown the superiority of prosthetic remodeling annuloplasty over the other surgical approaches. Despite this, suture-based annuloplasty remains the most commonly used technique for tricuspid valve repair(₁).

The Kalangos Biodegradable Tricuspid Ring (Kalangos Biodegradable Tricuspid Ring, Bioring SA, Lonay, Switzerland) is a novel prosthesis for the treatment of tricuspid insufficiency(₃).

In the study of Tang et al, 702 patients underwent TV repair, of which 493 had, predominantly, a De Vega procedure (no ring) and 209 had an annuloplasty ring (ring). TV pathology was functional (secondary) in 74% of patients. Concomitant procedures consisted of mitral valve surgery in 80% of patients, aortic valve surgery in 33%, and coronary bypass in 14%. Ring patients were younger and less likely to have coronary artery disease, more likely to be female and having had previous cardiac surgery. Long-term survival, event-free survival and freedom from recurrent TR were significantly better in the ring group, and there was a trend toward fewer TV reoperations. The use of an annuloplasty ring was an independent predictor of long-term survival and event-free survival(₄).

In the study of Burma et al, 15 patients with the diagnosis of moderate or severe functional tricuspid insufficiency were treated by implantation of a Kalangos Biodegradable Tricuspid Ring. Moderate and severe insufficiency was documented in 11 and 4 patients, respectively, in the preoperative tests. 1 and 6 months after surgery, 4 patients had trace and 1 patient had mild tricuspid insufficiency, while 10 patients had none. At the 1st and 6th month follow-up, systolic pulmonary arterial pressure, right atrial dimension and right ventricular diastolic diameter were found to be significantly lower than the preoperative values . The right atrial diameter and tricuspid valve area had decreased significantly(₃).

In conclusion of this study; Kalangos Biodegradable Ring is a promising prosthesis in patients with functional tricuspid insufficiency, with encouraging initial results(₃). Placement of an annuloplasty ring in patients undergoing tricuspid valve repair is associated with improved survival and event-free survival(₄). However, the concept of annulus remodeling using a biodegradable ring which preserves the growth potential of the native annulus opens new perspectives for valve repair procedures(₅).

Correspondence to

Doç. Dr. Ufuk YETKIN, 1379 Sok. No: 9,Burç Apt. D: 13 - 35220, Alsancak – IZMIR / TURKEY Tel: +90 505 3124906 , Fax: +90 232 2434848 e-mail: ufuk_yetkin@yahoo.fr