Cardioscopic Tricuspid Valve Repair in a Beating Ovine Heart


  • Ramanan Umakanthan
  • Ravi K. Ghanta
  • Aravind T. Rangaraj
  • Lawrence S. Lee
  • Rita G. Laurence
  • John A. Fox
  • Tomislav Mihaljevic
  • Ralph M. Bolman
  • Lawrence H. Cohn
  • Frederick Y. Chen



Background: Open heart surgery is commonly associated with cardiopulmonary bypass and cardioplegic arrest. The attendant risks of cardiopulmonary bypass may be prohibitive in high-risk patients. We present a novel endoscopic technique of performing tricuspid valve repair without cardiopulmonary bypass in a beating ovine heart.

Methods: Six sheep underwent sternotomy and creation of a right heart shunt to eliminate right atrial and right ventricular blood for clear visualization. The superior vena cava, inferior vena cava, pulmonary artery, and coronary sinus were cannulated, and the blood flow from these vessels was shunted into the pulmonary artery via a roller pump. The posterior leaflet of the tricuspid valve was partially excised to create tricuspid regurgitation, which was confirmed by Doppler echocardiography. A 7.0-mm fiberoptic videoscope was inserted into the right atrium to visualize the tricuspid valve. Under cardioscopic vision, an endoscopic needle driver was inserted into the right atrium, and a concentric stitch was placed along the posterior annulus to bicuspidize the tricuspid valve. Doppler echocardiography confirmed reduction of tricuspid regurgitation.

Results: All animals successfully underwent and tolerated the surgical procedure. The right heart shunt generated a bloodless field, facilitating cardioscopic tricuspid valve visualization. The endoscopic stitch resulted in annular plication and functional tricuspid valve bicuspidization, significantly reducing the degree of tricuspid regurgitation.

Conclusion: Cardioscopy enables less invasive, beating-heart tricuspid valve surgery in an ovine model. This technique may be useful in performing right heart surgery without cardiopulmonary bypass in high-risk patients.


Allen DS, Graham EA. 1922. Intracardiac surgery—a new method: preliminary report. JAMA 79:1028-30.nBolton HE, Bailey CP, Costas-Durieux J, Gemeinhardt W. 1954. Cardioscopy: simple and practical. J Thorac Surg 27:323-9.nBurke RP, Michielon G, Wernovsky G. 1994. Video-assisted cardioscopy in congenital heart operations. Ann Thorac Surg 58:864-8.nBurke RP, Rosenfeld HM, Wernovsky G, Jonas RA. 1995. Video-assisted thoracoscopic vascular ring devision in infants and children. J Am Coll Cardiol 25:943-7.nButterworth RF. 1951. A new operating cardioscope. J Thorac Surg 22:319-22.nCohen ST, Sell JE, McIntosh CL, Clark RE. 1987. Tricuspid regurgitation in patients with acquired, chronic, pure mitral regurgitation. II. Nonoperative management, tricuspid valve annuloplasty, and tricuspid valve replacement. J Thorac Cardiovasc Surg 94:488-97.nGhanta RK, Chen R, Narayanasamy N, et al. 2007. Suture bicuspidization of the tricuspid valve versus ring annuloplasty for repair of functional tricuspid regurgitation: midterm results of 237 consecutive patients. J Thorac Cardiovasc Surg 133:117-26.nHammon JW. 2008. Extracorporeal circulation. In: Cohn L, ed. Cardiac surgery in the adult. 3rd ed. New York, NY: McGraw-Hill. p 349-414.nInoue Y, Yozu R, Onoguchi K, Kabei N, Takeuchi S, Kawada S. 2003. Cardioscopic guidance of linear lesion creation for radiofrequency ablation. Ann Thorac Surg 75:1189-93.nInstitute of Laboratory Animal Research. 1996. Guide for the care and use of laboratory animals. Commission on Life Sciences, National Research Council. Washington, DC: National Academies Press. NIH publication 86-23.nKawai S, Okada R. 1987. A histopathological study of dilated cardiomyopathy—with special reference to clinical and pathological comparisons of the degeneration-predominant type and fibrosis-predominant type. Jpn Circ J 51:654-60.nLaborde F, Noirhomme P, Karam J, Batisse A, Bourel P, Saint Maurice O. 1993. A new video assisted thoracoscopic surgical technique for interruption of patent ductus arteriosus in infants and children. J Thorac Cardiovasc Surg 105:278-80.nLee KK, Yu HY, Chen YS, Chi NH, Chang CI, Wang SS. 2007. Off-pump tricuspid valve replacement for severe infective endocarditis. Ann Thorac Surg 84:309-11.nMazza IL, Jacobs JP, Aldousany A, Chang AC, Burke RP. 1998. Video-assisted cardioscopy for left ventricular thrombectomy in a child. Ann Thorac Surg 66:248-50.nMcGrath LB, Gonzalez-Lavin L, Bailey BM, Grunkemeier GL, Fernandez J, Laub GW. 1990. Tricuspid valve operations in 530 patients. Twenty-five-year assessment of early and late phase events. J Thorac Cardiovasc Surg 99:124-33.nMurray G. 1950. A cardioscope. Angiology 1:334-6.nOkada R, Kawai S. 1989. Classification of viral or idiopathic myocarditis by endomyocardial biopsy. Annual report of the Japanese Committee for Idiopathic Cardiomyopathy. p 18.nOshima T, Hirose J, Saski M, Morizuki O, Takahashi U. 1994. Detection of mural thrombus of the left ventricle by percutaneous cardioscopy. Presented at the Annual Meeting of the American Heart Association, 1994.nReuthebuch O, Roth M, Skwara W, Klovekorn W, Bauer EP. 1999. Cardioscopy: potential applications and benefit in cardiac surgery. Eur J Cardiothorac Surg 15:824-9.nRhea L, Walker IC, Cutler EC. 1924. The surgical treatment of mitral stenosis: experimental and clinical studies. Arch Surg 9:689-90.nRobin J, Tronc F, Vedrinne C, Champsaur G. 1999. Video-assisted tricuspid valve surgery: a new surgical option in endocarditis on pacemaker. Eur J Cardiothorac Surg 16:243-5.nUchida Y, Fujimori Y, Hirose J. 1990. Percutaneous left ventricular endomyocardial biopsy with angioscopic guidance. Am Heart J 119:949-52.nWirtz SP, Schmidt C, Van Aken H, Brodner G, Hammel D, Scheld HH, Berendes E. 2006. Temporary right heart support with percutaneous jugular access. Ann Thorac Surg 81:701-5.n



How to Cite

Umakanthan, R., Ghanta, R. K., Rangaraj, A. T., Lee, L. S., Laurence, R. G., Fox, J. A., Mihaljevic, T., Bolman, R. M., Cohn, L. H., & Chen, F. Y. (2009). Cardioscopic Tricuspid Valve Repair in a Beating Ovine Heart. The Heart Surgery Forum, 12(2), E90-E94.




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