[HSF] Traumatic tricuspid regurg

[Rwmfglycar at aol.com]

In a message dated 1/4/2007 4:12:16 A.M. Eastern Standard Time,  
nkkejriwal at gmail.com writes:

Dear  members

An interesting case has been referred to me. The patient is a  65 year old
lady who underwent dual chamber pacing a few years ago.  Recently she
presented to the cardiologist with pacemaker pocket site  infection. The
cultures did not grow any bug, but the generateor was  eroding through the
skin. Last week the cardiologist pulled out all the  hardwares. Apparently he
tore one of the pap m of the TV while removing the  RV lead. Now the patient
has severe TR. I am enclosing the echo frames  showing the bit of pap m with
attached chordae flopping in & out of RV  resulting in severe TR. The patient
had mild to mod TR before the lead  removal. There is no evidence of TV
endocarditis on echo. The annulus  measures 40mm. Normal coronaries.

What is the best option?
Repair by  suturing the muscle back and putting an annuloplasty ring? Will it
work? My  concern is that if the lead were infected, would it be wise to
leave the  leaflets behind?

Or, remove all the leaflets with chordae and insert a  bioprosthesis?
Dear Nand: she had some TricReg before the trauma.  This may have been due to 
the lead but may imply that she already has  an abnormal RV. Certainly the 
annulus is dilated. She has severe TR  now and there is absolutely no doubt in 
my mind that despite the publications  from Detroit in the past significant TR 
is not a normal state. We were very  much involved, 20 years ago, in the 
debates on valve excision versus  valve replacement for tricuspid endocarditis. We 
came down firmly on the side  of valve replacement or repair. We found poor 
outcomes with neglected or  deliberately produced severe Tric Reg. Futhermore as 
with all endocarditis we  found that appropriate antibiotics for only a few 
days protected against  recurrent infection whether we were doing replacement 
or repair. ( We came to  this opinion from left sided cases with severe failure 
as an imperative  indication for surgery without delay). 
 

I suspect this may have been erosion rather than infection. In  the absence 
of vegetations virtually all cases of endocarditis due to a  sensitive organism 
respond to antibiotics. Where do you think the  infection is? The lead is 
already out. The reason why the pap muscle tore is  because the lead was 
connected to it by fibrous healing. I believe you do not  need to wait for some 
arbitrary 4wks of time on antibiotics, which in the  absence of a positive culture 
may be useless anyhow.  What you do when  you get inside depends on the 
pathology. If the ruptured pap muscle is giving  rise to chordal support of only a 
small part of a leaflet (I could not  evaluate this because I could not open 
your attachment) you can do an  excision and annuloplasty and feel better about 
any unlikely  possibilty  of leaving residual infection behind. Neochordae are 
an option as is leaflet  and chordal replacement with pericardium (properly 
treated xenograft or  briefly tanned autogenous) 
I am also planning to attach RV &  LV epicardial leads. I shall sew the LV
lead close to the 1st OM artery  posteriorly. What is the best spot for the
RV lead?

I always thought the apex site gave better RV performance but  others have 
advocated an RV ouflow site. (It made no sense for me for the  ouflow part of 
the ventricle to contract first).
Yours 
Bob


Thanks

Nand


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