Repair of congenital tricuspid valve dysplasia: The croissant technique.

Central MessageRepair of a severely dysplastic tricuspid valve can be successfully performed by 2-leaflet, 1-patch augmentation using a crescent-shaped patch traversing the anteroseptal commissure.See Commentary on page XXX. Repair of a severely dysplastic tricuspid valve can be successfully performed by 2-leaflet, 1-patch augmentation using a crescent-shaped patch traversing the anteroseptal commissure. See Commentary on page XXX. Repair of non-Ebsteinoid tricuspid valve dysplasia (TVD) is often challenging due to severe leaflet restriction and lack of usable leaflet tissue.1Cleuziou J. Pringsheim M. Stroh A. Burri M. Lange R. Hörer J. Surgical treatment of tricuspid valve dysplasia in children.Eur J Cardio Thorac Surg. 2022; 62: 212Crossref Scopus (2) Google Scholar Few studies have investigated optimal surgical management strategies for this lesion.1Cleuziou J. Pringsheim M. Stroh A. Burri M. Lange R. Hörer J. Surgical treatment of tricuspid valve dysplasia in children.Eur J Cardio Thorac Surg. 2022; 62: 212Crossref Scopus (2) Google Scholar, 2Reddy V.M. McElhinney D.B. Brook M.M. Silverman N.H. Stanger P. Hanley F.L. Repair of congenital tricuspid valve abnormalities with artificial chordae tendineae.Ann Thorac Surg. 1998; 66: 172-176Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar, 3Mizuno M. Hoashi T. Sakaguchi H. Kagisaki K. Kitano M. Kurosaki K. et al.Application of cone reconstruction for neonatal Ebstein anomaly or tricuspid valve dysplasia.Ann Thorac Surg. 2016; 101: 1811-1817Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar Many surgical techniques have been borrowed from mitral valve repair, such as division of restrictive chordae, papillary muscle splitting, and pericardial patch splinting.4Bakir I. Onan B. Onan I.S. Gul M. Uslu N. Is rheumatic mitral valve repair still a feasible alternative?: indications, technique, and results.Tex Heart Inst J. 2013; 40: 163-169PubMed Google Scholar,5Gritti M. Ferris A. Shah A. Bacha E. Kalfa D. “Splint” mitral valve repair for destructive endocarditis in children.World J Pediatr Congenit Heart Surg. 2019; 10: 121-124Crossref Scopus (2) Google Scholar Herein, we describe a repair technique that addresses severe leaflet and commissure restriction with a 2-leaflet, 1-patch augmentation through the anteroseptal commissure itself and resection of restrictive secondary and primary chordae without the use of artificial chordae. Written informed consent was obtained for publication of this report. Approval was obtained from the Columbia University Medical Center Internal Review Board under protocol No. AAAR3476 (approved August 12, 2022). The patient is a 4-year-old boy (weight, 18 kg) with a prenatal diagnosis of pulmonary atresia with intact ventricular septum and TVD who underwent a transannular patch with right ventricular overhaul during the neonatal period. During an admission for COVID-19 pneumonia, the patient was found to have severe right ventricle dysfunction, free pulmonary regurgitation, and severe tricuspid regurgitation secondary to TVD. He was taken to the operating room for pulmonary valve replacement and a croissant repair of the TV. A midline sternotomy was performed and cardiopulmonary bypass was established. Pulmonary valve replacement was performed using a 21-mm Inspiris bioprosthesis (Edwards Lifesciences). The TV was inspected and repair was deemed feasible (Video 1). The septal and anterior leaflets were detached from the annulus, traversing across the anteroseptal commissure (Figure 1, D and E). Restrictive secondary chordae to both leaflets were divided. Restrictive secondary chordae to the posterior leaflet were also divided without taking down this leaflet. The anteroposterior papillary muscle was split to provide extra leaflet mobility (Figure 1, F). A croissant-shaped bovine pericardial patch was sutured to the annulus of the anterior and septal leaflets in a counterclockwise direction through the anteroseptal commissure (Figure 1, G). The free edge of the patch was trimmed in the shape of a croissant and sutured to the cut edge of both leaflets (Figure 1, H). Highly restrictive primary chordae at the anteroseptal commissure were divided. The septal and anterior leaflets in this region were splinted using thin strips of bovine pericardium (Figure 1, I and J). The annulus was then plicated at the posteroseptal aspect (Figure 1, K). A Hegar dilator (normal diameter for body surface area) was passed through the TV orifice without difficulty and saline testing revealed excellent leaflet mobility with trivial incompetence (Figure 1, L). The patient was weaned off bypass without difficulty in normal sinus rhythm. Postoperative transesophageal echocardiography demonstrated trace regurgitation without stenosis. The patient had an uneventful recovery. Interval echocardiograms have shown stable trivial tricuspid regurgitation and mild tricuspid stenosis (mean gradient, 2-3 mm Hg) at 12 months’ follow-up. The croissant technique for repair of congenital TVD combines 1 crescent-shaped patch for 2-leaflet augmentation crossing the anteroseptal commissure, along with resection of restrictive secondary and primary chordae and splint plasty for support of the augmented leaflets (Figure 2). This technique is innovative in that it untethers not only the leaflets but the anteroseptal commissure itself. Restriction of the mobility of the leaflets at the commissure is not well addressed with surgical techniques currently used to repair dysplastic TVs, even after extensive resection of the secondary chordae. Cutting primary chordae is often necessary to provide full mobility. Artificial chordae can be challenging in small children, do not have growth potential, and do not provide with a durable repair for this specific anatomy. Detaching the commissure itself from the annulus and patch-enlarging the commissure region, along with cutting primary chordae, gives full mobility to the leaflets. Buttressing the superior aspect of the septal leaflet and the inferior aspect of the anterior commissure with 2 thin strips of bovine pericardium sutured to the neoleaflet provides splint support to this tissue and enables resection of the primary chordae without inducing leaflet prolapse. The TV is thus bicuspidized, keeping the anteroposterior and posteroseptal commissures functional. This technique requires posterior leaflet mobility to be able to coapt with the neoanteroseptal leaflet, which in this case was provided by division of restrictive secondary chordae and splitting the anteroposterior papillary muscle. A similar technique could be applied to the posteroseptal commissure if this is the commissure with the greatest amount of restriction. The outcome of this repair is to untether and lengthen not only the restricted anterior and septal leaflets but also the anteroseptal commissure itself, producing a bicuspidized valve with excellent coaptation. The authors thank Sydney Williams for providing the illustrations. eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiIzNjgyYjhjMGY1MjEyYWRiMzgxOGU2YmQ1NWYxM2VkMSIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjg3NzIxMzM1fQ.cp-AqRn-F_RgSIhsa2mR7P8efgGOygOXckNdPRtwltQTAO-AfpCGQ2ZA09tcn98Y-mwaiulMmWcuH7jLvIVjn0viYiYq9W8nb5nX4J_Q_q5nSu4e6iFTdNJN07S-1IQDyAo4Pm5ipvOl1cnrm113kwdksudOghQZl98Fgu7u9AR1fnybOOLDblq81bnwN3puW5XKwJB950rDnbQQeRFQCg5QOuHTOKldLbe-bDjR-QY6nJ3it174JwgTVJp6C3H-bEEoNjL9ycpzquR_pNVs3odjjxZ7p4FpnU5_kCaWhzhjdKS-CsyfZB6mMAr8vvY9SN_QtRFPW3b-Y6hgvEGpng Download .mp4 (102.79 MB) Help with .mp4 files Video 1The croissant repair for congenital tricuspid valve dysplasia. Video available at: https://www.jtcvs.org/article/S2666-2507(23)00133-5/fulltext. Download .jpg (.15 MB) Help with files Video 1The croissant repair for congenital tricuspid valve dysplasia. Video available at: https://www.jtcvs.org/article/S2666-2507(23)00133-5/fulltext.