Tricuspid valve surgery

Tricuspid valve malformation is a rare congenital heart disease. The biggest feature of tricuspid valve malposition is difficulty breathing, palpitations, and even symptoms of heart failure. Currently, the best way to treat tricuspid valve malposition is surgery, but surgery is not a panacea. You must be suitable for surgical treatment and be fully prepared to achieve the best treatment effect. Let’s take a comprehensive look at the surgery for tricuspid valve malposition.

1. Indications for surgery

Indications: Patients have symptoms such as fatigue, palpitations, shortness of breath, arrhythmia, cyanosis, and heart failure. In cases without right-to-left shunt at the atrial level, right heart failure is particularly severe and intractable. On the contrary, in cases with patent foramen ovale or atrial septal defect, obvious cyanosis occurs due to right-to-left shunting, the symptoms of right heart failure are milder, and the ability to move is still significantly limited. The above-mentioned patients with right heart failure or cyanosis are all indications for surgery, and surgical treatment should be performed after a clear diagnosis.

2. Preoperative preparation and postoperative treatment

1. Cardiotonic and diuretic treatment should be used before surgery to alleviate symptoms of right heart failure such as hepatomegaly and ascites.

2. The patient's liver is enlarged, and congestion causes liver damage and prolonged prothrombin time. Vitamin K and prothrombin complex are required for treatment before surgery.

3. Surgical Method

1. Glenn operation is the superior vena cava-right pulmonary artery anastomosis. It can reduce the right heart load, reduce right-to-left shunt, increase arterial oxygen content, improve symptoms, and reduce cyanosis. However, it is a palliative surgery and does not solve the deformity. It is often used in young children with severe cyanosis who are not suitable for radical surgery. This surgery has good short-term effects, but poor long-term effects, and patients often die from arrhythmias.

2. Valve replacement surgery: The right atrium is opened under extracorporeal circulation, and the tricuspid valve, chordae tendineae and papillary muscles are cut off. Choose an appropriate artificial valve. In order to avoid damaging the cardiac conduction system, the artificial valve is sewn to the atrioventricular annulus in the front and to the right atrial septum a few millimeters away from the head of the coronary sinus opening in the back, so that the coronary sinus opening is moved to the ventricular cavity. The combined atrial septal defect was sutured closed at the same time. Patients with tricuspid valve descent have extremely enlarged right atrium, slow blood flow, and are prone to thrombosis. When replacing the tricuspid valve, the bioprosthesis has a central blood flow channel and its hemodynamic function is better than that of the mechanical valve. In addition, the right ventricular systolic pressure is not high, and the lifespan of the biological valve placed in the tricuspid valve position is significantly longer than that of the left heart biological valve, so it can be used as a valve of choice for valve replacement surgery.

3. Valvuloplasty uses multiple mattress-like Teflon felt sheets to fix the downward-moving septal leaflet and the root attachment area of ​​the posterior leaflet to the tricuspid valve ring, thereby reducing the enlarged valve ring and eliminating atrialized ventricles. In order to avoid conduction bundle block, the posterior leaflet can be repaired by using a double-ended needle and thread with a gasket. Two rows of parallel sutures are made from the junction of the posterior diaphragmatic leaflet to the junction of the posterior and anterior leaflets, 3 to 4 mm apart. The sutures are contracted with a gasket and then ligated to reduce the size of the tricuspid valve ring. Two finger widths are used as the objective standard. The closing function of the tricuspid valve is restored using the normally developed anterior leaflet. This surgery preserves the natural valve and eliminates the potential risks of artificial valves, but it can only be used in cases where the anterior leaflet of the tricuspid valve develops normally, and there is still a certain degree of insufficiency after the operation.

Active medical treatment is still required after the operation to control heart failure and arrhythmia, closely observe serum potassium, sodium, chloride levels and electrocardiogram changes, and supplement potassium chloride in time. After the operation, pay attention to keeping the drainage tube open and take measures such as transfusing fibrinogen and fresh blood to stop bleeding. After the operation, cyanosis disappeared, the liver shrank, the ascites disappeared, and the cardiac shadow also shrank significantly. The therapeutic effect was satisfactory.