Functional TR in the OR: What To Do?
A 60-year-old man presented to the hospital complaining of severe shortness of breath for 2 weeks. His medical history was significant for daily alcohol consumption and occasional marijuana use. After being originally admitted for pneumonia, it was discovered on transthoracic echocardiography that he had severe aortic regurgitation, a dilated left ventricle with ejection fraction of 30-35%, and moderate-to-severe functional mitral regurgitation. His right ventricle (RV) was also noted to be depressed with some tricuspid regurgitation (TR) present that was difficult to quantify due to poor imaging windows. He was taken to the operating room for aortic and mitral valve replacements.
Following induction of anesthesia and placement of invasive monitors, his central venous pressure was noted to be 21 mmHg, and his pulmonary artery pressures were 48/29, with a mean of 37 mmHg. Transesophageal echocardiography (TEE) imaging confirmed the left-sided valvular lesions, as well as a dilated and severely depressed left ventricle (Video 1). The RV was also dilated and moderately depressed (Videos 2-3). The tricuspid valve leaflets appeared tethered (Video 4), resulting in at least moderate TR by color flow Doppler (Videos 5-6). The tricuspid annulus was noted to be dilated, measuring >40 mm in diameter (Figure1).
In addition to the left-sided valve surgery, what tricuspid valve intervention should be performed?