Second Chance Heart: Navigating Tricuspid Valve Repair After Mitral Valve Surgery

Tricuspid valve regurgitation often emerges after surgery addressing left-sided valve issues, especially involving the mitral valve. Though the tricuspid valve leaflets and chordae might be healthy, the tricuspid annulus dilates due to sustained volume and pressure overload on the right ventricle. This contrasts with primary TR, where the valve itself is diseased. Over time, the tricuspid annulus flattens, potentially restricting the valve due to leaflet tethering from the right ventricle's dilation. Addressing the mitral valve might not always resolve these secondary tricuspid valve problems, sometimes requiring direct intervention on the tricuspid valve.

Guidelines suggest considering tricuspid valve surgery if, following left-sided valve surgery, a patient develops severe tricuspid regurgitation alongside symptoms or progressive right-ventricular dilatation or dysfunction. This is contingent on the absence of concurrent left-sided valve dysfunction, severe dysfunction in either ventricle, or advanced pulmonary vascular disease. The European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS) recommend considering tricuspid valve surgery at the time of left-sided surgery in patients with severe secondary TR and even in those with mild to moderate TR if the annulus is dilated.

Patients needing tricuspid valve re-intervention often present late, years after their initial mitral valve surgery, leading to an extensively dilated and thinned right ventricle. Accompanying issues like cardiac-related congestion, liver cirrhosis, ascites, renal failure, or esophageal varices can arise from the tricuspid regurgitation, affecting the patient's prognosis. This necessitates thorough preoperative evaluation and preparation to manage these complications before addressing the tricuspid valve.

Severe dysfunction in either the right or left ventricle, unresolved left-sided valve problems, and severe pulmonary hypertension might preclude redo tricuspid valve surgery. These contraindications stem from the increased surgical risk and the challenges the right ventricle faces in adapting to pressure rather than volume overload post-surgery. Post-Operative Challenges: Post-surgery, the right ventricle must adapt to handling pressure rather than volume overload, a condition it typically tolerates less effectively than the left ventricle.

Accessing the tricuspid valve during reoperation can be challenging. While median sternotomy (a traditional chest incision) can be risky due to potential injury to the thin right ventricle, a minimally invasive approach through the right side may be feasible if there are no extensive pleural adhesions. This approach involves cannulation of the femoral artery and vein, as well as the right jugular vein, to establish cardiopulmonary bypass. Balloon catheters may be used to block the vena cavae, achieving complete bypass without clamping or snaring vessels.