Cardiovascular Journal of Africa: Vol 32 No 5 (SEPTEMBER/OCTOBER 2021)

CARDIOVASCULAR JOURNAL OF AFRICA • Volume 32, No 5, September/October 2021 284 AFRICA Case Report Stubbornly preserving native leaflets is not always right: a case of tricuspid valve re-operation Lijie Jiang, Xueshan Zhao, Jiao Li, Zhong Wu Abstract Tricuspid valve replacement is becoming more and more popular at various medical centres due to the increase in numbers of patients with tricuspid regurgitation. We report on a case of a 59-year-old man who had undergone tricuspid valve replacement with preservation of the native leaflets two years earlier, and developed early prosthetic dysfunction, which may have been caused by fusion of the native valve leaflets with the prosthetic valve leaflets. The experience of this case informs us that preserving the subvalvular apparatus may impede the motion of the prosthesis, and that adapt- ing the individual morphology of the native tricuspid valve during tricuspid valve replacement could benefit the patient and avoid re-operation. Keywords: cardiac surgical procedures, heart valve prosthesis implantation, re-operation Submitted 21/3/21, accepted 14/4/21 Published online 26/4/21 Cardiovasc J Afr 2021; 32 : 284–286 www.cvja.co.za DOI: 10.5830/CVJA-2021-019 With the increase in morbidity rate of tricuspid regurgitation, tricuspid valve replacement (TVR) is becoming more and more popular. However, the pathogenesis of prosthetic valve dysfunction after TVR is not entirely understood. 1 From experience, the main cause is pannus formation on the prosthetic cusps on the side of the right ventricle. At the same time, the reason that the native valve leaflets attach to the prosthesis should not be neglected. 2 We present a case of early decay of the tricuspid prosthesis due to preserving the native valve leaflets during the first operation, which restricted the closure of the prosthesis. Case report A 59-year-old man developed dyspnoea on exertion of one year duration. Transthoracic echocardiography showed severe tricuspid regurgitation. He was then diagnosed with rheumatic heart disease and underwent TVR at another hospital with the choice of a bioprosthetic valve (Carpentier–Edwards PERIMOUNT tricuspid bioprosthetic valve, 31 mm) on the basis of his age. On the 12th day after the operation, he was discharged from hospital and six months of oral anticoagulant therapy was prescribed. However, the patient developed worsening dyspnoea on exertion two years after the operation and was admitted to our hospital. Physical examination showedahigh-pitched, pansystolic murmur in the fourth intercostal space of the parasternal region. Transthoracic echocardiography revealed poor closing of the bioprosthetic valve, causing severe regurgitation from the valve orifice rather than perivalvular leakage. Transoesophageal echocardiography (Fig. 1) demonstrated a regurgitant jet from the anterior cusp of the bioprosthetic valve. Coronary arteriography showed a healthy coronary artery system. Re-operation was done via a routine median sternotomy, and cardiopulmonary bypass was set up through the ascending aorta and superior/inferior vena cava after separating the pericardium from the heart. Cross clamping and cardioplegic cardiac arrest were routinely performed and the tricuspid valve was exposed with a right atriotomy. The bioprosthetic valve was in situ , closely Department of Cardiovascular Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, PR China Lijie Jiang, MD Xueshan Zhao, MD Zhong Wu, wuzhong71@scu.edu.cn Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, PR China Jiao Li, MD Fig. 1. Transoesophageal echocardiography: the regurgitant jet from the anterior cusp of the bioprosthetic valve.