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 Table of Contents  
Year : 2021  |  Volume : 54  |  Issue : 6  |  Page : 238-240

Tricuspid regurgitation after endomyocardial biopsy

Division of Cardiovascular Surgery, Heart Center, Cheng Hsin General Hospital, Taipei, Taiwan

Date of Submission15-Jul-2021
Date of Decision27-Jul-2021
Date of Acceptance29-Oct-2021
Date of Web Publication30-Nov-2021

Correspondence Address:
Chia-Ju Tsai
Division of Cardiovascular Surgery, Heart Center, Cheng Hsin General Hospital, Taipei
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/fjs.fjs_154_21

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Tricuspid regurgitation (TR) is a relatively uncommon complication subsequent to endomyocardial biopsy. We are reporting a 21-year-old male who underwent biopsy 13 times following heart transplantation. Symptomatic TR prompted the need for surgical repair, thus annuloplasty with artificial chordae reimplantation was performed. Mild TR with the preserved function was documented nearly 4 years after surgical intervention.

Keywords: Endomyocardial biopsy, heart transplant, tricuspid regurgitation, tricuspid valve repair

How to cite this article:
Tsai CJ, Chen IC, Chang CY. Tricuspid regurgitation after endomyocardial biopsy. Formos J Surg 2021;54:238-40

How to cite this URL:
Tsai CJ, Chen IC, Chang CY. Tricuspid regurgitation after endomyocardial biopsy. Formos J Surg [serial online] 2021 [cited 2022 Aug 8];54:238-40. Available from: https://www.e-fjs.org/text.asp?2021/54/6/238/331636

  Introduction Top

Endomyocardial biopsy remains the gold standard for allograft rejection staging and guide to subsequent immunosuppression regimen. Complications related to the biopsy procedure have been reported to include cardiac perforation with tamponade, embolization, arrhythmias, conduction disturbances, and damage to the tricuspid valve apparatus causing regurgitation.[1] Tricuspid regurgitation (TR) is a relatively uncommon complication with a prevalence between 5% and 15%.[2] There is a significant correlation between the total number of endomyocardial biopsies performed and the development of flailed tricuspid leaflets or chordal rupture.[3] We are reporting a case of biopsy-induced TR with a flail leaflet which is repaired successfully with artificial chordae reimplantation on the leaflet and annuloplasty ring technique.

  Case Report Top

A 21-year-old male with familial hypertrophic cardiomyopathy who suffered from severe left ventricular dysfunction with an ejection fraction of 16% and moderate mitral regurgitation. He received orthotopic heart transplantation in October 2011. A triple-drug immunosuppressive therapy was commenced immediately and he was discharged 4 weeks after transplantation.

At regular evaluation after transplantation, he underwent endomyocardial biopsy 13 times and echocardiography 18 times. Follow-up echocardiography showed normal ventricular dimensions and functional indices. Furthermore, mild TR without obvious chordae or leaflet tissue defects was identified. After endomyocardial biopsy in February 2017, the patient complained of progressive malaise and dyspnea on exertion in March. Transthoracic echocardiography revealed moderate to severe TR. After aggressive medical treatment, symptoms still progressed. Transthoracic echocardiography in July 2017 revealed severe TR, right atrial enlargement and a flailed leaflet [Figure 1]. Therefore, surgical intervention was planned.
Figure 1: Transthoracic echocardiogram 6 years after heart transplantation showing severe TR with a flail leaflet

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On October 27, 2017, surgery was carried out via a re-do median sternotomy. After full heparinization, cardiopulmonary bypass was established with the right common femoral artery, right femoral vein, and right internal jugular vein. Dense adhesions were released, and tapes were passed around the superior and inferior vena cavae. Heart arrest was achieved by histidine-tryptophan-ketoglutarate cardioplegia solution. The right atrium was then opened after tapes were snagged down. On examining the leaflets of the tricuspid valve, posterior leaflet chordae rupture was identified along with significant annulus dilation. Valve repair was performed with artificial chordal reimplantation (Gore-Tex sutures) from papillary muscle to posterior tricuspid leaflet (1 set of 3 loops) and a 30 mm Edward MC3 annuloplasty ring was placed for dilated annulus. After 130 min, weaning from cardiopulmonary bypass was uneventful, and the ischemic time was 67 min. Blood loss was 500 ml. Intra-operative transesophageal echocardiography showed minimal TR after heartbeats was resuscitated. The patient went through a rather rapid recovery, without complication. Postoperative echocardiography demonstrated trivial TR only.

The most recent transthoracic echocardiography on this otherwise functional patient (NYHA functional class I) on March 9, 2021, revealed only mild TR nearly 4 years postoperative.

  Discussion Top

TR has been identified in up to 86% of patients after orthotopic heart transplantation, but evidence shows severe TR only at around 10% at 5 years and 15% at 10 years.[4] The etiology of TR could be caused by: (1) Escalated pulmonary vascular resistance;[5] (2) Graft rejection with annular dilatation and papillary muscle dysfunction;[6] (3) Distortion of the right atrium and tricuspid annulus related to atrial anastomosis or altered cardiac geometry from commonly observed pericardial cavity enlargement;[7] (4) Damaged subvalvular or valvular apparatus during the endomyocardial biopsy.[8]

TR is a relatively uncommon complication from the endomyocardial biopsy with a prevalence between 5% and 15%.[2] The ideal target location for obtaining myocardial samples is the interventricular septum, but the chordae tendineae usually arise from the papillary muscles and the septal wall close to the sample site. The forceps of the cardiac bioptome may tear the valve leaflets, chordae, or papillary muscles, which are all capable of causing TR.[9] There have been reports on a direct correlation between the overall number of biopsies and the severity of TR.[10]

Moderate or severe TR usually can be managed with diuretics and afterload reduction. Surgical intervention is indicated only for symptomatic patients. Currently available data support surgical treatment for severe TR as the most effective management for intractable right-heart failure and show significant improvement in quality of life.[11]

To prevent recurrent damage, 2- or 3-dimensional echocardiography-guided endomyocardial biopsy has been reported to protect the tricuspid valve.[12] It allows for a better choice of biopsy sites and avoids damage to cardiac structures. However, although the tricuspid valve may be identified, the chords and subvalvular apparatus are still very difficult to identify and avoid with the bioptome. Besides, the viewing windows for the right ventricle are not always satisfactory. Another study mentions that a long sheath inserted for biopsy and traversing the tricuspid valve can protect the valve from the bioptome.[13] This avoids contact with the chords or subvalvular apparatus and decreases the chance of making damage to the sutures. Furthermore, the long sheath lacks bioptome mobility and makes it much more difficult to search for new areas on repeated endomyocardial biopsies.

Several surgical techniques have been described to repair flailed valve leaflets in the past. “Mitralization” of the tricuspid valve works when posterior leaflets are nearly completely flailed.[14] Flailed leaflets can be repaired by quadrangular resection with plication of the corresponding annulus plus annuloplasty ring.[15] The triple leaflet edge-to-edge technique (clover technique) is relatively easier, less time-consuming, and allows effective restoration for adequate valvular competence.[9] However, annuloplasty is necessary when there is a significant compromise of right ventricular function or any form of overload.

In this case, the culprit tricuspid valve leaflets were repaired with chordal replacement using a “premeasured” Gore-Tex chordal loop. First, the “premeasured” Gore-Tex chordal loop traversed through the tip of the papillary muscle and the end of the loop is then secured to the prolapsing leaflet with Cardionyl sutures. We had a lot of experience in artificial chordal reimplantation for mitral valve repair surgery. This technique has an advantage for relative ease in determining the proper length of the replacement chordae, and reduces unforced chordal extension during fixation.[16] Therefore, we concluded that artificial chordae with annuloplasty ring repair provide a reasonable resolution for symptomatic and biopsy-related TR in heart transplant patients.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Calé R, Almeida M, Gonçalves P, Rebocho MJ, Raposo L, Teles R, et al. Complications of endomyocardial biopsy after heart transplantation: A lesser evil. Rev Port Cardiol 2012;31:159-62.  Back to cited text no. 1
Huddleston CB, Rosenbloom M, Goldstein JA, Pasque MK. Biopsy-induced tricuspid regurgitation after cardiac transplantation. Ann Thorac Surg 1994;57:832-6.  Back to cited text no. 2
Tucker PA, Jin BS 2nd, Gaos CM, Radovancevic B, Frazier OH, Wilansky S, et al. Flail tricuspid leaflet after multiple biopsies following orthotopic heart transplantation: Echocardiographic and hemodynamic correlation. J Heart Lung Transplant 1994;13:466-72.  Back to cited text no. 3
Chan MC, Giannetti N, Kato T, Kornbluth M, Oyer P, Valantine HA, et al. Severe tricuspid regurgitation after heart transplantation. J Heart Lung Transplant 2001;20:709-17.  Back to cited text no. 4
Lewen MK, Bryg RJ, Miller LW, Williams GA, Labovitz AJ. Tricuspid regurgitation by Doppler echocardiography after orthotopic cardiac transplantation. Am J Cardiol 1987;59:1371-4.  Back to cited text no. 5
Hausen B, Albes JM, Rohde R, Demertzis S, Mügge A, Schäfers HJ. Tricuspid valve regurgitation attributable to endomyocardial biopsies and rejection in heart transplantation. Ann Thorac Surg 1995;59:1134-40.  Back to cited text no. 6
Haverich A, Albes JM, Fahrenkamp G, Schäfers HJ, Wahlers T, Heublein B. Intraoperative echocardiography to detect and prevent tricuspid valve regurgitation after heart transplantation. Eur J Cardiothorac Surg 1991;5:41-5.  Back to cited text no. 7
Aziz TM, Burgess MI, Rahman AN, Campbell CS, Deiraniya AK, Yonan NA. Risk factors for tricuspid valve regurgitation after orthotopic heart transplantation. Ann Thorac Surg 1999;68:1247-51.  Back to cited text no. 8
Navia JL, Atik FA, Vega PR, Garcia M, Starling RC, Gonzalez-Stawinski GV, et al. Tricuspid valve repair for biopsy-induced regurgitation in a heart transplant recipient. J Heart Valve Dis 2005;14:264-7.  Back to cited text no. 9
Nguyen V, Cantarovich M, Cecere R, Giannetti N. Tricuspid regurgitation after cardiac transplantation: How many biopsies are too many? J Heart Lung Transplant 2005;24:S227-31.  Back to cited text no. 10
McCreery CJ, McCulloch M, Ahmad M, deFilippi CR. Real-time 3-dimensional echocardiography imaging for right ventricular endomyocardial biopsy: A comparison with fluoroscopy. J Am Soc Echocardiogr 2001;14:927-33.  Back to cited text no. 11
Williams MJ, Lee MY, DiSalvo TG, Dec GW, Picard MH, Palacios IF, et al. Biopsy-induced flail tricuspid leaflet and tricuspid regurgitation following orthotopic cardiac transplantation. Am J Cardiol 1996;77:1339-44.  Back to cited text no. 12
Wong RC, Abrahams Z, Hanna M, Pangrace J, Gonzalez-Stawinski G, Starling R, et al. Tricuspid regurgitation after cardiac transplantation: An old problem revisited. J Heart Lung Transplant 2008;27:247-52.  Back to cited text no. 13
Kay JH. Surgical treatment of tricuspid regurgitation. Ann Thorac Surg 1992;53:1132-3.  Back to cited text no. 14
Smith JA, Large SR. Tricuspid valve repair for tricuspid regurgitation after endomyocardial biopsy. J Heart Lung Transplant 1995;14:199.  Back to cited text no. 15
von Oppell UO, Mohr FW. Chordal replacement for both minimally invasive and conventional mitral valve surgery using premeasured Gore-Tex loops. Ann Thorac Surg 2000;70:2166-8.  Back to cited text no. 16


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