Tricuspid Regurgitation Resulting Operative monitoring was started. The patient’s arterial

From Acute Type A AorticDissectionKazuhiro Kurisu, MD, Hironori Baba, MD,Hidehiko Nakashima, MD, Takashi Kajiwara, MD,Manabu Hisahara, MD, Kunihiko Joo, MD, andYoshie Ochiai, MD

Department of Cardiovascular Surgery, Kyushu Kosei NenkinHospital, Kitakyushu, Japan

Proximal extension of acute type A aortic dissection canaffect the aortic valve but seldom affects the tricuspidvalve. We report the case of an octogenarian who un-derwent successful surgical repair of an aortic dissectionthat was accompanied by tricuspid regurgitation. Webelieve that the tricuspid regurgitation was attributableto displacement of the valve resulting from aorticdissection.

(Ann Thorac Surg 2014;98:e5–6)� 2014 by The Society of Thoracic Surgeons

roximal extension of acute type A aortic dissection

Poften infiltrates the aortic root, resulting in aorticvalve insufficiency [1, 2], but seldom affects the tricuspidvalve [3]. We report the case of an octogenarian patientwho underwent surgical repair of an aortic dissectionthat was accompanied by tricuspid regurgitation. Webelieve the etiology of the tricuspid regurgitation tohave been displacement of the valve by the bulging ofthe false lumen in the interatrial septum.

An 81-year-old woman experienced sudden severeanterior chest and back pain and was brought to theemergency room at our facility, where she was diag-nosed with acute type A aortic dissection. She had beenfollowed for ascending aortic aneurysm, aortic valvedisease, and chronic atrial fibrillation; echocardiography2 years before had shown mild aortic stenosis andregurgitation and trivial tricuspid regurgitation. Elec-trocardiography showed atrial fibrillation with a heartrate of 87 beats per minute and no ST-segment or T-wave changes. Chest X-ray demonstrated mild enlarge-ment of the mediastinal shadow. Laboratory studyrevealed troponin T to be negative. Computed tomog-raphy showed a communicating aortic dissection inthe ascending aorta and aortic arch with a maximumdiameter of 64 mm. An entry tear was found near theaortic root, and mild pericardial effusion was also iden-tified. Echocardiography confirmed fairly preserved leftventricular contraction and no exacerbation of aorticvalve disease. The patient was immediately taken to theoperating room.

Accepted for publication April 4, 2014.

Address correspondence to Dr Kurisu, Department of CardiovascularSurgery, Kyushu Kosei Nenkin Hospital, 1-8-1 Kishinoura, Yahatanishi-ku, Kitakyushu 806-8501, Japan; e-mail: kkurisu@qkn-hosp.jp.

� 2014 by The Society of Thoracic SurgeonsPublished by Elsevier Inc

pressure was approximately 75 mm Hg and centralvenous pressure was 21 mm Hg. Conventional mediansternotomy followed by pericardiotomy was performed.After drainage of serosanguineous fluid in the pericardialspace, central venous pressure decreased to 14 mm Hgbut gradually increased again to 20 mm Hg thereafter.The right atrium was markedly expanded, and trans-esophageal echocardiography revealed massive regurgi-tation through the tricuspid valve. Cardiopulmonarybypass was established with perfusion through theright femoral artery and bicaval drainage. Myocardialprotection was achieved with cold crystalloid cardioplegiaadministered by direct coronary perfusion. Transectionof the ascending aorta was performed, revealing theentry tear identified preoperatively above the sinotubularjunction. The dissection extended mainly into the non-coronary sinus and partially into the right and left coro-nary sinuses. Resuspension of a detached commissurebetween the right and noncoronary cusps was performedusing a pledgeted polypropylene suture. BioGlue (Cry-oLife, Kennesaw, GA) was used to obliterate the falselumen in the proximal aorta and the ascending aortawas replaced, accompanied by antegrade selective cere-bral perfusion with a minimum rectal temperature of24.4�C. After rewarming, the tricuspid regurgitationremained mild before weaning the patient from cardio-pulmonary bypass. However, immediately after cessationof cardiopulmonary bypass, the regurgitation becamemassive (Fig 1). The patient’s arterial pressure couldnot be maintained over 80 mm Hg despite volumeloading and a central venous pressure of over 12 mmHg. Cardiopulmonary bypass was restarted, the heartrearrested, and the right atrium opened. The leafletand subvalvular apparatus of the tricuspid valve wasintact, but bulging of the false lumen adjacent to theanteroseptal commissure was identified. The bulgingwas seen to displace the septal leaflet of the tricuspidvalve. The decision was made to perform tricuspid ringannuloplasty to restore the displaced valve to its normal

Fig 1. Intraoperative transesophageal echocardiography showingmassive tricuspid regurgitation. (RA ¼ right atrium; RV ¼ rightventricle.)

0003-4975/$36.00http://dx.doi.org/10.1016/j.athoracsur.2014.04.053

e6 CASE REPORT KURISU ET AL Ann Thorac SurgTR DUE TO ACUTE AORTIC DISSECTION 2014;98:e5–6

position. A 28-mm Edwards MC3 annuloplasty ring(Edwards LifeSciences, Irvine, CA) was positioned bymeans of 10 mattress sutures of 2-0 polyester. There wasa dramatic decrease in tricuspid regurgitation andimprovement in the patient’s hemodynamic status, witha central venous pressure of approximately 7 mm Hg,after weaning from cardiopulmonary bypass. Thepatient had an uneventful postoperative course and wasdischarged in excellent condition with trivial tricuspidregurgitation on echocardiography.

Comment

Extension of acute aortic dissection often involves theaortic root and leads to aortic valve insufficiency, withan incidence of moderate to severe regurgitation of44% to 48% [1, 2]. However, involvement of the othervalves is extremely rare. Tricuspid regurgitation dueto aortic dissection has been reported only once [3].Vyas and colleagues [3] concluded, on the basis ofintraoperative inspection and postmortem examination,that displacement of the septal leaflet of the tricuspidvalve caused by aortic dissection extending into theinteratrial septum had resulted in regurgitation. Webelieve that the tricuspid regurgitation in the presentcase was related to the aortic dissection for 2 reasons.One is the absence of significant tricuspid regurgitationbefore the acute onset of aortic dissection. The patienthad led a normal life, without congestive heart failure,and tricuspid regurgitation noted on echocardiography2 years prior had been trivial. The other reason for ourbelief that the tricuspid regurgitation was related to thedissection is that the displacement of the valveobserved intraoperatively, with no abnormality of theleaflet itself, closely resembled that previouslydescribed [3]. We now evaluate the function of both thetricuspid and aortic valves in cases of type A aorticdissection.

Gibbs and colleagues [4] described a similar case inwhich an unruptured aneurysm of the sinus of Valsalva

protruded into the right atrium adjacent to the septalleaflet of the tricuspid valve. This caused the patient tosuffer from tricuspid stenosis and insufficiency.We initially expected repair of the aortic dissection,

including evacuation of hematoma followed by oblitera-tion of the false lumen, to correct the displacement ofthe tricuspid valve and reduce the regurgitation, butthis did not occur. The displacement was not easilyrestored because the false lumen continued to bulge afterrepair of the aortic dissection. We expected ring annulo-plasty rather than suture annuloplasty to be better ableto control the regurgitation because restoration of thedisplaced valve as well as reduction of annular size wasnecessary. The three-dimensional design and saddle-shaped configuration of the Edwards MC3 annuloplastyring [5] is suitable for such a repair.In conclusion, we report an extremely rare case of a

patient who experienced tricuspid regurgitation resultingfrom an acute type A aortic dissection. Ring annuloplastycan be a reasonable solution to correcting a displacedtricuspid valve.

References

1. Movsowitz HD, Levine RA, Hilgenberg AD, Isselbacher EM.Transesophageal echocardiographic description of the mech-anisms of aortic regurgitation in acute type A aortic dissection:implications for aortic valve repair. J Am Coll Cardiol 2000;36:884–90.

2. Campbell-Lloyd AJM, Mundy J, Pinto N, et al. Contemporaryresults following surgical repair of acute type A aorticdissection (AAAD): a single centre experience. Heart. LungCirc 2010;19:665–72.

3. Vyas PR, Wright CB, Driedger H, Flege JB Jr. Tricuspidincompetence resulting from retrograde aortic dissection.J Cardiovasc Surg 1987;28:585–7.

4. Gibbs KL, Reardon MJ, Strickman NE, et al. Hemodynamiccompromise (tricuspid stenosis and insufficiency) caused byan unruptured aneurysm of the sinus of Valsalva. J Am CollCardiol 1986;7:1177–81.

5. Filsoufi F, Salzberg SP, Coutu M, Adams DH. A three-dimensional ring annuloplasty for the treatment of tricuspidregurgitation. Ann Thorac Surg 2006;81:2273–7.