First echocardiogram was made 8 months before the heart team evaluation. Trans-esophageal echocardiography (TEE) shows severe mitral regurgitation, which is likely caused by a restrictive posterior valve. Moderate left atrium dilatation was found. Left ventricular ejection fraction was measured 47%. Two months prior to operation severe tricuspid regurgitation was found on Trans thoracic echocardiography (TTE) , as shown in Fig. 7.2. The annulus of the tricuspid valve measured 48 mm. The heart team concludes that left sided valve intervention is necessary and concomitant tricuspid valve surgery is indicated. This decision is supported by the current ESC-guidelines [4].

Patients was electively admitted for mitral and tricuspid valve surgery. Operation was done by median sternotomy. After central bi-caval cannulation the circulation is taken over by cardio pulmonary bypass and after aortic cross clamping, cardioplegia was admitted. The left atrium was opened via Waterston’s groove and the mitral valve is exposed. A Mitral Physio-ring (Edwards Lifescience) size 26 is implanted in the dilated annulus. The left atrium is closed with 4 × 0 Prolene sutures. The right atrium is opened and the tricuspid valve is exposed. The annulus is dilated and septal leaflet tissue is limited. This wasn’t noted on preoperative echocardiography images. A Tricuspid Physioring (Edward Lifescience) size 32 is implanted with Tricon 2 × 0 annular sutures. The right atrium is closed with Prolene 4 × 0 sutures. During removal of the aortic cross clamp and venting the aortic ascendens major ST deviations followed by ventricular fibrillation occurs, most likely due to coronary air embolisms. After defibrillating the rhythm converted to sinus rhythm. Temporary epicardial pacemaker leads were left on the right ventricle and the sternum was closed by steel wires. Subsequently, the skin was closed by staplers. Both the mitral and tricuspid ring are shown in Fig. 7.3a.

The patient is admitted to the intensive care unit and recovered successfully without any significant events. Postoperative TTE shows a trace of mitral regurgitation and still severe residual tricuspid regurgitation, as shown in Fig. 7.3b. In this particular case, the limited valve tissue could be the reason of persistent malcoaption. Annuloplasty, by implantation of a rigid ring alone, without valve leaflet augmentation has resulted in a failed repair.

This patient is discussed twice in a heart team meeting. The first meeting took place after echocardiographic imaging which showed a severely dilated right ventricle, as shown in Fig. 7.4a. Right ventricle dimensions are 87 mm for apex to basis and the annulus measured 59 mm. Systolic function of the right ventricle is graded as moderate. Mean pulmonary artery pressure (mPAP) is mildly increased (30 mmHg). Fig. 7.4b displays massive tricuspid regurgitation which is probably caused by both right ventricular dilatation and cardiac pacemaker lead interference of the tricuspid valve. 3D echocardiography confirms this suspicion (Fig. 7.4c). The left heart has fractional shortening of 40%, which is graded as a moderate systolic function. Only mild mitral regurgitation is noticed.

The heart team initially concludes that the congestive right heart failure is caused by tricuspid regurgitation with volume overload, primary right ventricular failure and the lack of AV synchrony. However, the consensus is reached to prescribe a medical therapy in the first place and not to operate this patient because of the unpredictable outcome of and uncertainty of tricuspid valve repair and the expected high operation risks (due to age and pre-existed kidney failure). The consensus is discussed with the patient and he agrees with the proposed medical treatment.

During the following months the right heart failure persisted and the patient needs to be admitted for intravenous diuretic treatment. In the second meeting the heart team decides to perform the high risk operation due to persistent right heart failure on medications. Additionally, the VVI-pacemaker system is to be replaced for an epicardial system, due to interference with tricuspid valve leaflets causing severe tricuspid regurgitation.

Patient is electively admitted at our center and underwent surgery of the tricuspid valve, a coronary artery bypass graft (CABG) and removal of the endovascular DDD pacemaker system, which is replaced with a epicardial DDD pacemaker system . Operation was done via median sternotomy. After central and bi-caval cannulation, circulation is taken over by cardio pulmonary bypass. Because of pre-existed kidney failure blood pressure is kept at 70 mmHg, resulting in good diuresis during surgery. The operation is performed on beating heart without aorta cross clamping. The distal right coronary artery is calcified and this vessel is grafted by a vena saphenous magna (VSM) graft . On beating heart the right atrium is opened and the tricuspid valve is exposed. The atrial lead is located in the auricle, but the lead had grown into the anterior part of the right atrium and also in the anterior part of the tricuspid annulus, resulting in deformation of the tricuspid annulus. The ventricular lead originates from the VCS following the posterior wall of the atrium to the inter-commissural area of the tricuspid annulus and pushed the septal leaflet laterally, in which the lead also have grown into. Carefully, both pacemaker leads are removed and a small defect on the septal leaflet is sutured by prolene 6 × 0 sutures, without leaflet extention. A Tricuspid Physio (Edwards Lifescience) ring size 34 is implanted and the tricuspid valve appears sufficient with watertest. New epicardial leads are introduced and are connected to a Biotronik pacemaker , which is placed at the dorsal left side of the rectus abdominis. Peri-operative TEE showed signifcant diminished tricuspid valve regurgitation.