Quadrangular Resection of the Tricuspid Valve
A 58-year-old male presented with progressive dyspnea of insidious onset that he had for a month. On echocardiographic examination, the right heart was markedly enlarged, and large, freely moving vegetation was seen on the tricuspid valve with severe tricuspid regurgitation (). The blood cultures were negative. On follow-up echocardiography of two week intervals, tricuspid regurgitation was persistent, but the vegetation disappeared. New patch infiltrations developed in both of the lung fields suggesting septic emboli from the vegetations.\nThe patient underwent surgery after 6 weeks of antibiotic treatment. Median sternotomy was performed, and the operation was carried out under standard hypothermic cardiopulmonary bypass and cardioplegic arrest. When exploring the tricuspid valve from a right atriotomy, the septal and posterior leaflets were intact but a significant area of the anterior leaflet had destructed including all the chordae arising from the anterior papillary muscle. When meticulous trimming of the destructed valve leaflet was completed, we realized that the appearance of the surgical field was very similar to the one seen in a quadrangular resection. Based on the idea that the anterior leaflet of the tricuspid valve is similar to the posterior leaflet of the mitral valve in its structure and function, we reapproximated and sewed-up each of the remaining leaflet remnants to the annulus, which is commonly performed in quadrangular resection of mitral valve repair (). Instead of applying a valve ring, we performed De Vega annuloplasty (). The valve became completely competent after the repair based on a saline loading test. The patient's postoperative recovery was event-free. The congestive heart failure rapidly resolved, and he remained symptomless for the following 8 years. Tricuspid regurgitation was trivial on a late echocardiogram performed eight years after the operation.