A pacing system infection may lead to infective endocarditis and systemic sepsis. Tricuspid valve surgery may be required if the valve is severely damaged in the process of endocarditis. Although, cardiopulmonary bypass is the safe choice for performing right-heart procedures, it may carry risk of inducing systemic inflammatory response and multi-organ dysfunction. Some studies have advocated TV surgery without institution of CPB. We report tricuspid valve excision using the off-pump inflow occlusion technique in a 68-year-old man. We also describe role of intra-operative TEE as a monitoring tool at different stages of the surgical procedure. .
How to cite this article: Gadhinglajkar S, Sreedhar R, Karunakaran J, Misra M, Somasundaram G, Mathew T. Tricuspid valve excision using off-pump inflow occlusion technique: Role of intra-operative trans-esophageal echocardiography. Ann Card Anaesth 2010;13:148-53
How to cite this URL: Gadhinglajkar S, Sreedhar R, Karunakaran J, Misra M, Somasundaram G, Mathew T. Tricuspid valve excision using off-pump inflow occlusion technique: Role of intra-operative trans-esophageal echocardiography. Ann Card Anaesth [serial online] 2010 [cited 2022 May 19];13:148-53. Available from: https://www.annals.in/text.asp?2010/13/2/148/62929
0A pacing system infection may lead to infective endocarditis (IE) and systemic sepsis. Tricuspid valve (TV) damage occurs frequently in the endocarditis. Surgical strategies to deal with such a TV include valve reconstruction or replacement on cardiopulmonary bypass (CPB)., Intra-operative hemodynamic stability is better maintained when a right-heart surgery is performed on-CPB rather than without CPB. For this reason, the use of CPB has become a routine during the TV surgery.
However, CPB is known to induce generalized inflammatory response , that carries the risk of multi-organ dysfunction. The inflammatory response may be of concern in a septic patient with pneumonia and deranged renal function in whom the damaging pulmonary and renal effects of CPB may precipitate respiratory and renal failure respectively. Hence, some studies have advocated TV surgery without institution of CPB., We are reporting a patient, in whom the TV endocarditis had escalated to cause sepsis and multi-organ dysfunction. He was treated with pacing lead explantation and tricuspid valvectomy using the off-pump inflow occlusion technique. We describe the utility of trans-esophageal echocardiography (TEE) during the procedure.
A 68-year-old male patient was diagnosed with sick-sinus syndrome and had undergone transvenous pacemaker implantation 18 years ago. He presented to us with infection in the left deltopectoral groove, where the pulse generator (PG) was implanted, since four weeks. The infection resulted in high grade fever; sepsis; deranged hepatic and renal function; and pneumonia in both lungs. As the antibiotic course of injection meropenem was begun in the referring centre, his blood culture was found sterile for any micro-organisms on admission to our centre. However, we added teicoplannin injection to the medications to treat the respiratory infection. Diagnosis of possible IE was considered, based on serial echo-cardiographic evaluation and Duke's major and minor criterion (transthoracic echocardiographic features of vegetations and high grade fever in the presence of endovascular pacing leads). As the antibiotic combinations failed to eradicate pneumonia, PG pocket infection and sepsis completely, he was referred for surgical explantation of the infected pacing system and surgery on the TV. Intravenous drug abuse, as a cause of infective endocarditis, was ruled out on elicitation of the history.
The patient could maintain a mean arterial pressure (MAP) in the range of 70-90 mmHg. The pacemaker system had stopped functioning since weeks. Despite that, the heart was beating in sinus rhythms, at a rate of 80/ minute, without temporary pacing requirement. The latest pre-operative transthoracic echocardiography (TTE) a day prior to surgery revealed vegetations bigger than 10 mm in size on the TV and papillary muscles and moderate tricuspid regurgitation (TR). Other features were intact interatrial septum (IAS) and absence of patent foramen ovale (PFO); dilated right ventricle (RV) and left ventricular ejection fraction (LVEF) of 68%. However, on TTE examination, possibility of tricuspid valve peri-annular abscess, right heart fistulae and pulmonary valvular vegetations was not ruled out..The pre-operative total white cell count and C-reactive proteins were elevated to 15100 cells/cubic mm and 28 mg/dl respectively (Normal 4300-10900 cells/cubic mm and less than 5-6 mg/dl respectively). Bio-chemical investigations were suggestive of deranged hepatic and renal function [Creatinine 3.9 mg/dl (normal: 0.8-1.2 mg/dl), total bilirubin 4.2 mg/dl (normal 0.3-1.0 mg/dl) and Serum Glutamic-Pyruvic Transaminase 64 IU/L (normal 5-40 IU/L)]. Besides antibiotics, he was not receiving any other medication.
On the day of surgery, the patient was pre-medicated with oral diazepam 7.5 mg 45 minutes before transfer to the operation unit. The heart rate and blood pressure (BP) before surgery were 75/ minute, and 128/80 mmHg respectively. Anesthesia was induced in the 58 kg weighing patient with intravenous fentanyl 500 mcg, midazolam 5 mg, propofol 30 mg and pancuronium 10 mg. After endotracheal intubation, the lungs were ventilated using oxygen + air (inspired oxygen 33%) and anesthesia was maintained with isoflurane (in the range of 0.75 to 1 MAC), fentanyl 500 mcg and midazolam 5 mg. Routine parameters like ECG, SpO2, EtCO2, urine output, and nasopharyngeal temperature were monitored in addition to the central venous pressure, (CVP) via right internal jugular vein and invasive arterial pressure were monitored, in addition to the central venous pressure, (CVP) via right internal jugular vein and invasive arterial pressure. The central venous pressure was about 9-10 mmHg. To mimic the basal conditions for TEE examination, MAP was restored to near normal. Cardiac examination was performed using a multi-plane TEE probe and ultrasound machine (HD Envisor, Philips Ultrasound, US). It confirmed the TTE findings of the vegetations on all tricuspid leaflets and papillary muscles. The septal leaflet vegetations were of 1.4 cm X 1.1 cm size; oscillating; situated on the right atrial side of the valve [Figure 1]. The TV examination displayed a perforated septal leaflet [Figure 2], thickened posterior leaflet and flail anterior leaflet (Video 1)- . No peri-annular abscess or fistula was detected. One of the two pacing leads studded with vegetations could be traced in the RA. Other features were presence of multiple jets of moderate grade TR; diastolic paradoxical movements of the inter-ventricular septum (IVS); and absence of PFO and atrial septal defect (ASD). Pulmonary valve, mitral and aortic valves were free from vegetations. Some of the echo-cardiographic values pertaining to the pre-operative and post-operative right and left ventricular function are summarized in [Table 1]. The left ventricular fractional area change (LVFAC) was calculated on trans-gastric mid-short axis view (MIDSAX) view. The tricuspid annular plane systolic excursion (TAPSE); right ventricular fractional area change (RVFAC); and RV/ LV end-diastolic diameter ratio were derived from the four-chamber view.
It was decided to proceed with the surgery using inflow occlusion technique without the CPB. The PG was extracted before proceeding with the sternotomy. After sternotomy, the Superior vena cava (SVC) and inferior vena cava (IVC) were looped and kept ready for occlusion. According to institutional protocol, intravenous mannitol 30 gm and dexamethasone 16 mg were injected; and normoglycemia was maintained for brain protection before inflow occlusion. Nasopharyngeal temperature was reduced to 33.5 degree Celsius using water blankets and ambient surface cooling. After injection of heparin 60 mg, the activated clotting time (ACT) was 324 seconds. Inspired concentration of oxygen was stepped up to 100% before inflow occlusion. The patient was placed in Trendelenburg position which increased the CVP to 12 mmHg. Then the SVC and the IVC were snared to achieve complete inflow occlusion. Systolic BP dropped to 15-20 mmHg and CVP increased to 25 mmHg during the period of occlusion. An incision was placed on the right atrial appendage and blood within the right atrium (RA) was suctioned out to have a clear view of the TV. During the first occlusion of the vena cavae for 1.5 minutes, the surgeon extracted 2 endocardial pacing leads and excised the septal leaflets along with the anterior leaflet. The RA and RV were filled with normal saline before snares were released. The MAP increased to 50-60 mmHg after the release of inflow occlusion snares. The TEE examination after the first inflow occlusion showed air bubbles on the right side of the heart and partly excised TV (Video 2)- . The right heart was full of air bubbles [Figure 3], while no air was seen in the left atrium (LA). A portion of the septal leaflet, the posterior leaflet and tricuspid annular vegetations were still left behind. Excision of the remnant leaflets and papillary vegetations and debridement of the annulus were done during second inflow occlusion lasting for 1minute 45 seconds. The total amount of estimated blood loss during surgery was 900-1000 ml, however, as a cell saver was not available, it was replenished with two units of whole blood and 400 ml fresh frozen plasma in addition to a liter of crystalloids and colloids. Infusion of Epinephrine 0.05 mcg/ kg/ minute and norepinephrine 0.05 mcg/ kg/ minute were commenced to maintain stable hemodynamics after completion of second inflow occlusion. The mean CVP had crept up to 12-15 mmHg when patient was placed in supine position. Protamine 40 mg was injected to reverse the heparin effect, which brought the ACT down to 112 seconds. The remaining portion of the pacing leads was subsequently pulled out from the pacemaker pocket in the left infra-clavicular area. After completion of the valvectomy, the TEE observations were: enlarged RV; dilated coronary sinus (Video 3)- ; and free TR jet causing flow reversal in the hepatic vein. The ventricular septum exhibited a paradoxical motion during end-diastole, resuming its position at the end-systole. The RA was characteristically enlarging in systole, displacing the atrial septum to left (Video 4)- . The TAPSE and RVFAC revealed a marginal improvement [Table 1]. The patient could maintain a heart rate of about 80-90/ minute without external pacing. After transferring the patient to the intensive care unit at the end of surgery, he was ventilated electively for 18 hours. The CVP remained elevated for about a week. Remarkable recovery from sepsis occurred within a week after the surgery and he was subsequently discharged after two days. When reviewed after a month, TTE examination showed slight improvement in the biventricular function.
TV endocarditis can occur in one to seven per cent of patients after the permanent pacemaker implantation., It can culminate into a life threatening systemic sepsis with multiorgan dysfunction. TV surgery was required in our patient, who had medically refractory and advanced infection featuring perforation of leaflets, presence of large vegetations, shower of the septic emboli to pulmonary artery and systemic sepsis. The presence of PFO or an ASD is an absolute indication to operate the TV on CPB, because of the intra-operative danger of air or infected tissue debris traversing paradoxically in to the systemic vascular tree. The damaged TV may be surgically dealt with by extraction, repair or replacement. Instituting CPB is usually essential to perform later two procedures. As repair of the damaged TV has become a routine strategy in many surgical centers, institution of CPB has been accepted as the standard method to provide intraoperative hemodynamic stability and a safe and reliable environment for surgeons. If the patient is hemodynamically unstable before surgery, or if the surgical expertise is lacking, CPB would be a safer option for the patient. However, CPB induced inflammatory reactions are known to have detrimental effects on lungs and kidneys., This .is a matter of concern in an IE related septic patient with renal dysfunction and bilateral pneumonia, who risks precipitation of postoperative renal and respiratory failure. The advocates of inflow occlusion technique have recommended avoiding CPB in such selective patients for better preservation of organs. Tricuspid valvectomy is less time consuming than TV repair or replacement and is hemodynamically tolerated well by majority of the patients. Arbulu et al. have proposed it as a treatment option in patients with IE. However, inflow occlusion interrupts the cardiac filling, which results in acute drop in the forward cardiac output and severe systemic hypotension. The coronary blood supply to myocardium is also jeopardized during the inflow occlusion. Since inflow occlusion is always restricted to a brief duration (less than two minutes),myocardial ischemia may be limited to a minimum extent. If a patient can maintain a stable hemodynamics before surgery, a brief period of venous occlusion may be endured well by the heart. Other major problems with the inflow occlusion technique are attributed to the absence of cardiac output (severe systemic hypotension; ischemia of brain, and other vital organs); and back-pressure changes of venous occlusion (cerebral edema, facial congestion). Tightening the snares on major caval veins results in a significant distention of the SVC, which impedes cerebral venous drainage. Thus the brain is vulnerable to ischemia both due to systemic hypotension and rise in the cerebral venous pressure. Tricuspid valvectomy may be complicated with bleeding from an open RA; injury to the atrial and ventricular septum; and perforation of heart. Because of these reasons, performing right-sided open heart surgery on CPB is the accepted method of current practice and the inflow occlusion technique has been left with limited indications. However, the problems of tricuspid valvectomy and inflow occlusion may be kept under limitation to a great extent by maintaining of a high surgical precision and strictly restricting the maximum duration of inflow occlusion to two minutes at a time. A cell saver is useful to salvage blood during the surgery and to avoid transfusion related immunological insult.
As angiography is contra-indicated, diagnosis of IE and related cardiac evaluation relies on the echocardiography (American heart association class I recommendation; level of evidence A). Both TTE and TEE have important roles in the diagnosis and management of patients with suspected IE., When imaging is sub-optimal or definitive evidence is not provided by trans-thoracic approach, trans-esophageal imaging should be considered. Imaging TEE at higher frequencies (6-7 MHz) than TTE (2-4 MHz) allows for greater spatial resolution of the cardiac valves. Under ideal conditions, TTE can reliably identify only those structures, which are larger than 5 mm in diameter, whereas TEE can depict structures as small as 1 mm. Both the techniques have demonstrated high sensitivity for the diagnosis of right sided lesions. However, TEE has an edge over TTE in the diagnosis of conditions associated with IE like isolated Staphylococcus aureus TV infection, periannular abscess, fistulae and pulmonary valve vegetations. The trans-esophageal approach provides a better view on the RA, the IAS, the SVC, and the pulmonary valve. Before the commencement of surgery, the TV should be thoroughly inspected for the IE features and also mechanism involved in the regurgitation. The anterior and septal leaflets are well seen in the ME four-chamber view. Posterior leaflet can be inspected near coronary sinus by retroflexing and slightly advancing the probe from ME four-chamber view or in a modified RV inflow-outflow view by turning the probe clockwise from aortic valve at 90 degrees. Esophageal navigation of the heart could enable us to verify the preoperative transthoracic observations. Jassal et al. have reported that a significant correlation exists between the surgical findings and the preoperative TEE assessment of vegetations, abscess, and cusp perforations.
Even though inflow occlusion technique permitted open inspection of the TV in our patient, TEE inspection after each episode of occlusion was of immense help to determine the extent of excision performed and that which would be required further. The presence of pacing wire, valve cusps and vegetations remnants was excluded after the second endeavor. TEE also ruled out the sequelae of the atrial and ventricular sepal perforation that would allow air bubbles to cross over to the left heart. After completion of the surgery, TEE findings in the intra-operative period should be regarded as a new baseline for the post-operative evaluation of valvular and ventricular function.
Free TR jet causing systolic flow reversal in hepatic vein, coronary sinus dilatation and right ventricular distention is commonly observed in a trivalvular heart. Characteristically, the RA enlarges during systole and pushes the IAS leftward. Tricuspid valvectomy results in acute right ventricular volume overload, which eventually reduces the LVEF. The mechanism of left ventricular dysfunction is explained by Louie et al. who evaluated postoperative echo-cardiographic changes in 10 patients subjected to TV excision for endocarditis. They reported that despite a volume-replete LV, resting LVEF was significantly depressed due to the volume-overload of the RV as a consequence of impaired septal-free wall systolic shortening. However, the systolic fractional shortening along the left ventricular long axis was preserved. The right ventricular volume overload results in shift of the ventricular septum leftward and toward the center of the LV at end-diastole with restoration to more normal geometry at end-systole. The late-diastolic filling at the time of atrial systole is relatively diminished. However, it does not compromise on overall left ventricular filling. This abnormal displacement of the ventricular septum opposes the normal forces of left ventricular distention. The restoration of normal ventricular septal curvature at end-systole results in inefficient systolic contraction. As a result, the net shortening along the ventricular septum-to-posterolateral free wall short axis in a volume-overloaded RV is depressed. Postoperative LVEF in these patients ranged from 46 to 57%, remaining less than 50% in 4 subjects. All these echo-cardiographic features were observed in the intra-operative period in our patient. If the biventricular dysfunction is poorly tolerated, it becomes mandatory for the surgical team to replace the TV on the CPB. TEE confirmed in our patient that the systolic function of the dilated RV did not change significantly after surgery, although it may be attributed partly to the use of inotropes. The left ventricular function (LVFAC) had deranged to some extent. As biventricular function was adequate enough to maintain a stable hemodynamic condition in the immediate peri-operative period and TV replacement was not required. TV excision for endocarditis may be hemodynamically tolerated well by the patients over many years and valve replacement may be performed electively at a later date. It is shown that intravenous drug abusers patients with intractable right-sided IE have the best chance of cure and long-term survival by undergoing tricuspid or tricuspid and pulmonary valve excision(s), without prosthetic replacement. Of 38 long-term survivors (range 9-29 years), 35 had a tri-valvular heart. Our patient is kept under a regular follow up to determine the necessity for TV replacement in future.
In summary, intra-operative TEE is a valuable tool to guide the TV surgery using inflow occlusion. It can detect the presence of PFO, pulmonary valve vegetations, peri-annular abscess and fistulae prior to the surgery, which may be important features to decide the nature of surgery and may not be convincingly detected on the TTE. TEE inspection during the surgical procedure helps to determine the extent of valve excision performed and that which would be required further. It also rules out the perforation of cardiac chambers that would result in the paradoxical air embolism. After the procedure, TEE can estimate the degree of right ventricular distension and left ventricular systolic dysfunction which guides the necessity of tricuspid valve replacement.
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Correspondence Address: Shrinivas Gadhinglajkar Department of Anaesthesia, Sree Chitra Tirunal Institute For Medical Sciences and Technology, Thiruvananthaparum, Kerala - 695 011 India
Source of Support: None, Conflict of Interest: None