Cardioscopic Tricuspid Valve Repair in a Beating Ovine Heart
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
Author Disclosure & Copyright Transfer Agreement
In order to publish the original work of another person(s), The Heart Surgery Forum® must receive an acknowledgment of the Author Agreement and Copyright Transfer Statement transferring to Forum Multimedia Publishing, L.L.C., a subsidiary of Carden Jennings Publishing Co., Ltd. the exclusive rights to print and distribute the author(s) work in all media forms. Failure to check Copyright Transfer agreement box below will delay publication of the manuscript.
A current form follows:
The author(s) hereby transfer(s), assign(s), or otherwise convey(s) all copyright ownership of the manuscript submitted to Forum Multimedia Publishing, LLC (Publisher). The copyright transfer covers the exclusive rights to reproduce and distribute the article and the material contained therein throughout the world in all languages and in all media of expression now known or later developed, including but not limited to reprints, photographic reproduction, microfilm, electronic data processing (including programming, storage, and transmission to other electronic data record(s), or any other reproductions of similar nature), and translations.
However, Publisher grants back to the author(s) the following:
- The right to make and distribute copies of all or part of this work for use of the author(s) in teaching;
- The right to use, after publication in The Heart Surgery Forum, all or part of the material from this work in a book by the author(s), or in a collection of work by the author(s);
- The royalty-free right to make copies of this work for internal distribution within the institution/company that employs the author(s) subject to the provisions below for a work-made-for-hire;
- The right to use figures and tables from this work, and up to 250 words of text, for any purpose;
- The right to make oral presentations of material from this work.
Publisher reserves the right to grant or refuse permission to third parties to republish all or part of the article or translations thereof. To republish, such third parties must obtain written permission from the Publisher. (This is in accordance with the Copyright Statute, United States Code, Title 17. Exception: If all authors were bona fide officers or employees of the U.S. Government at the time the paper was prepared, the work is a “work of the US Government” (prepared by an officer or employee of the US Government as part of official duties), and therefore is not subject to US copyright; such exception should be indicated on signature lines. If this work was prepared under US Government contract or grant, the US Government may reproduce, royalty-free, all or portions of this work and may authorize others to do so, for official US Government purposes only, if the US Government contract or grant so requires.
I have participated in the conception and design of this work and in the writing of the manuscript and take public responsibility for it. Neither this manuscript nor one with substantially similar content under my authorship has been published, has been submitted for publication elsewhere, or will be submitted for publication elsewhere while under consideration by The Heart Surgery Forum, except as described in an attachment. I have reviewed this manuscript (original version) and approve its submission. If I am listed above as corresponding author, I will provide all authors with information regarding this manuscript and will obtain their approval before submitting any revision. I attest to the validity, accuracy, and legitimacy of the content of the manuscript and understand that Publisher assumes no responsibility for the validity, accuracy, and legitimacy of its content. I warrant that this manuscript is original with me and that I have full power to make this Agreement. I warrant that it contains no matter that is libelous or otherwise unlawful or that invades individual privacy or infringes any copyright or other proprietary right. I agree to indemnify and hold Publisher harmless of and from any claim made against Publisher that relates to or arises out of the publication of the manuscript and agree that this indemnification shall include payment of all costs and expenses relating to the defense of any such claim, including all reasonable attorney’s fees.
I warrant that I have no financial interest in the drugs, devices, or procedures described in the manuscript (except as disclosed in the attached statement).
I state that the institutional Human Subjects Committee and/or the Ethics Committee approved the clinical protocol reported in this manuscript for the use of experimental techniques, drugs, or devices in human subjects and appropriate informed consent documents were utilized.
Furthermore, I state that any and all animals used for experimental purposes received humane care in USDA registered facilities in compliance with the “Principles of Laboratory Animal Care” formulated by the National Society for Medical Research and the “Guide for the Care and Use of Laboratory Animals” prepared by the Institute of Laboratory Animal Resources and published by the National Institutes of Health (NIH Publication No. 85-23, revised 1985).