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.