Endoscopic Tricuspid Valve Surgery is a Safe and Effective Option

Abstract

<jats:sec><jats:title>Objective</jats:title><jats:p> Isolated tricuspid surgery through median sternotomy can be associated with a high morbidity and mortality. Reports of minimally invasive isolated tricuspid valve operations are rare, but the outcomes are encouraging. We present our experience of endoscopic isolated tricuspid valve surgery. </jats:p></jats:sec><jats:sec><jats:title>Methods</jats:title><jats:p> In our institution, 452 patients underwent endoscopic minimal access cardiac surgery between August 2008 and December 2018. A total of 90 patients underwent tricuspid valve surgery whether isolated or with other cardiac procedure. We further selected patients who had isolated tricuspid valve surgery ( n = 24). Of these patients, 13 (54%) had more than one previous sternotomy. </jats:p></jats:sec><jats:sec><jats:title>Results</jats:title><jats:p> Tricuspid repair was performed in 18 patients (75%) with the remaining 6 (25%) having bioprosthetic tricuspid replacement. Three (12.5%) were performed with a beating heart, the remaining with endoaortic clamping and cardioplegia. There were no conversions to sternotomy. None of the patients had reoperation for bleeding, tamponade, or valve issues. Three patients (12.5%) required blood transfusion, 3 patients (12.5%) required renal dialysis, and 7 patients (29%) had respiratory complications such as chest infection, requiring continuous positive airway pressure (CPAP) with 2 being re-intubated. One patient (4.1%) died within 30 days from chest sepsis leading to multi-organ failure. Mean hospital stay was 11.1 ± 8.9 days (median of 8). All patients had mild or less regurgitation on follow-up echo at 6 months. </jats:p></jats:sec><jats:sec><jats:title>Conclusions</jats:title><jats:p> Isolated tricuspid valve surgery can be performed through an endoscopic minimally access approach, with good results. It appears to provide better results than a sternotomy approach. A high repair rate can be achieved, and the procedure is particularly valuable in redo-surgery with low mortality and morbidity compared to historical sternotomy case series. </jats:p></jats:sec>

Minimally invasive tricuspid valve surgery

“…Our results showed total bypass times of 139.8±46.4 minutes. This also reflects that we used the endovascular occlusion clamp in most of the cases which increases the bypass times (5). Chen and colleagues reported a total bypass time of 74.8±28.5 min in their 117 patients with isolated tricuspid surgery patients.…”

“…Routine work up is the same as sternotomy approach which includes echocardiogram, 12 lead electrocardiogram (ECG), chest X-ray, routine blood tests and preoperative examination (5).…”

“…Finally, the incisions became more cosmetic by the introduction the peri areolar incisions (Figure 2) without compromising the quality of the procedure (16). Many centres mentioned using blunt dissection and muscle splitting techniques while performing the mini thoracotomy to promote better healing and less pain post operatively (5).…”

“…There are many solutions for pacing after the procedure. The most commonly used one in the primary cases is placing the standard epicardial pacing wires into the epicardial surface of the right ventricle (5). Other options are mainly used for the redo cases where dissection of adhesions is avoided to avoid injury of the cardiac structures or the previous bypass grafts.…”

“…Immediate post-operative care of the minimally invasive patients is the same as standard sternotomy patients. Most centres insisted on having an immediate post-operative chest X-ray to ensure right lung expansion, confirm the position of the right pleural drain and exclude unilateral pulmonary congestion (5). Some centres adopted quick removal of the drains within 24-48 hours post-surgery (37).…”