Case Presentation
A 43-year-old man with medical history significant for TR was referred
to our center for surgical management of his TV following annual
transthoracic echocardiogram (TTE) that revealed severe TR with
moderately enlarged right atrium and right ventricle (RV). The patient
was born in a foreign country and was told by his mother that he was
diagnosed with a heart murmur and congenital TR as a child prior to
immigrating to the United States. He denied chest trauma, intravenous
drug use, history of rheumatic fever, or connective tissue disorder. The
patient was an avid hiker and reported occasional palpitations, but was
otherwise asymptomatic. In order to further assess TV morphology, the
patient underwent 2- and 3-dimensional transesophageal echocardiogram
(TEE) and cardiac magnetic resonance imaging (MRI). TEE confirmed severe
TR with evidence of a flail anterior TV leaflet and a dilated tricuspid
annulus measuring 5.4cm (Figures 1 and 2). The regurgitant jet was
eccentric and directed toward the septal wall of the atrium (Figure 3).
Cardiac MRI demonstrated a severely dilated RV with normal systolic
function and normal left ventricular size with mildly decreased systolic
function. Although the patient was asymptomatic, to prevent further RV
dilatation and development of right heart failure, the patient was taken
to the operating room for elective TVr. Institutional Review Board
approval and informed patient consent was waived given the case report
nature of the manuscript.
In the operating room, evaluation of the TV revealed a severely dilated
annulus. The septal and posterior leaflets were normal in appearance,
while the anterior leaflet was redundant with thickened edges. The
chordae tendineae of the anterior leaflet appeared to be elongated
without evidence of chordal rupture. The papillary muscles appeared to
be normal. An Alfieri clover repair was performed. A running 5-0
polypropylene suture was placed between the edges of the anterior,
septal, and posterior leaflets to effectively reduce the height of the
redundant leaflets. A 32mm Contour 3D (Medtronic, Minneapolis, MN)
tricuspid annuloplasty band was added to complete and stabilize the
repair. The repair was evaluated by saline filling of the right
ventricle, which demonstrated no residual TR. TEE assessment of the
valve after weaning from cardiopulmonary bypass confirmed an acceptable
repair with mild TR and a mean pressure gradient of 1 mmHg across the
valve (Figure 4). The patient had an uneventful postoperative course and
was discharged home on postoperative day 3. On follow-up, the patient
was doing well with no signs or symptoms of right heart failure.