In the pediatric population, surgical repair of the tricuspid valve may be required for tricuspid insufficiency or stenosis, Ebstein's anomaly, or other rare lesions.
Operations are carried out working through a right atriotomy using cardiopul- monary bypass, moderate hypothermia (26°C), aortic cross-clamping and car- dioplegia, profound local cardiac cooling, and left ventricular venting. Children with tricuspid atresia require single ventricle surgery and this is covered in Chapter 6.
3-1. Tricuspid Insufficiency - DeVega Annuloplasty
FIGURE 3-1. In this child with an atrial septal defect (ASD) and tricuspid insufficiency, the tricuspid valve annulus is dilated, resulting in severe central insufficiency.
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anterior leaf
FIGURE 3-2. The tricuspid insufficiency is repaired with a DeVega annuloplasty. A running mattress suture of monofilament material with Teflon® felt support at the ends is placed adjacent to the tricuspid valve annulus. The first arm of the stitch runs immediately adja- cent to the annulus, while the second arm is placed more remote from the annulus. The stitch begins opposite the coronary sinus and anterior to the bundle of His. The concept of this procedure is to narrow the annulus at the base of the posterior tricuspid valve leaf.
After tying the stitch, the valve is tested by filling the right ventricle with saline from a syringe. The ASD is then closed primarily.
3-2. Ebstein's Anomaly 3-2-1. Mild Ebstein's Anomaly
atrial septal defect
septal leaf
coronary
posterior leaf
annulus
> L caud
FIGURE 3-3. In this child with mild Ebstein's anomaly, the tricuspid valve septal leaf is attached to the septum about 1cm remote from the native valve annulus. The pos- terior aspect of the posterior leaf is also attached directly to the septum.
ceph R < - - • L
caud
septal leaf
posterior leaf
annulus
FIGURE 3-4. The septal leaf is underdeveloped and located remote from the annulus.
Anteriorly, its attachment in the region of the commissure is at the annulus.
repaired atrial septal defect
repair suture
caud
FIGURE 3-5. The septal and posterior leafs do not meet and in this area with each is attached to the ventricular septum remote from the tricuspid valve annulus.
atrial septal defect
repair suture
FIGURE 3-6. The repair is performed by placing a continuous mattress suture of monofil- ament material with Teflon® felt support. The stitch is placed deep to the tricuspid valve annulus. With this procedure, the septal and posterior leafs will be approximated so that they meet near the annulus to form a new commissure. The ASD is closed primarily.
3-2-2. Severe Ebstein's Anomaly
ceph R < - - • L
caud
right atrium
right ventricle
FIGURE 3-7. The right atrium is markedly distended due to tricuspid insufficiency.
ceph R < -
caud - • L
"sail like"
anterior leaf
FIGURE 3-8. After placing the child on cardiopulmonary bypass, the right atrium is incised and a segment of the wall removed to reduce the size of the atrium. The large "sail-like"
anterior leaf comprises most of the functional tricuspid valve.
divided free margin of anterior leaf base
caud
fibrous bands
FIGURE 3-9. The base of the anterior leaf is divided from the annulus from an area near the commissure with the septal leaf and extending toward the posterior leaf. By reflect- ing the free margin of the anterior leaf, multiple fibrous bands are seen attaching the mid part of the leaflet to the free wall of the right ventricle. These fibrous attachments will be divided in order to mobilize the anterior leaf.
R ^
freed anterior leaf
FIGURE 3-10. After dividing the fibrous bands, the anterior leaf is more mobile and is free floating.
ceph R < - - • L
caud
continuous suture to reattach anterior leaf to annulus
reattached anterior leaf
ventricular plication stitches
atrial plication stitches
FIGURE 3-11. Multiple felted mattress sutures are placed in a longitudinal fashion in the septum/post wall from the tricuspid valve annulus extending toward the apex of the ven- tricle in order to plicate the posterior wall. This plication is placed posterior and toward the right from the region of the coronary sinus and bundle of His. The thinned portion of the posterior wall of the ventricle is obliterated in order to improve ventricular function postoperatively. Plication sutures are extended into the right atrium posteriorly. The free- floating anterior leaf is shifted clockwise and reattached to the tricuspid valve annulus with a continuous suture. This leaf is positioned so that the end of it will meet the region of the septal leaf in order to obliterate completely the atrialized portion of the ventricle.
3-2-3. Duplication of Tricuspid Valve with Double Inlet Left Ventricle
ceph
caud - • L
atrial septal defect
tricuspid valve orifice to right ventricle
tricuspid valve orifice to left ventricle
FIGURE 3-12. In this child there is duplication of the tricuspid valve. One orifice enters the right ventricle, while the duplicated orifice enters the left ventricle. This can be verified by viewing the left ventricle through the ASD.
ceph R < - - • L
caud
chords
papillary muscle
valve leaf
FIGURE 3-13. The duplicated left ventricular orifice includes valve leaflets as well as rudi- mentary papillary muscles and chords. This orifice is regurgitant, which allowed a left-to- right intracardiac shunt.
ceph R < - - • L
caud
orifice to left ventricle
chords
FIGURE 3-14. The tricuspid orifice entering the right ventricle was adequate in size so the repair was performed by closure of the duplicated left ventricular tricuspid orifice. Mul- tiple stitches are placed in the base of these valve leaflets.
orifice to right ventricle
patch
caud
FIGURE 3-15. Repair sutures are placed in a Dacron® patch to close the left ventricular orifice of the duplicated tricuspid valve. The ASD is then closed primarily.
