A Novel Approach to Tricuspid Valve Replacement: The Upside Down Stentless Aortic Bioprosthesis

Tricuspid valve replacement (TVR) is a rarely needed operation. Choices between mechanical and biological prosthesis still generate controversy. We present our initial clinical experience with a stentless aortic root placed inverted in the tricuspid annulus. Between August 2000 and September 2003, TVR for severe tricuspid insufficiency was performed in 8 patients. Indications were infective endocarditis (7) and iatrogenic damage (1). Mean age was 42.2 years old (20 to 58 years old). Five patients were male and 3 patients had a concomitant procedure (mitral valvuloplasty, coronary bypass grafting, and aortic valve replacement). A stentless aortic root, size 27 mm (n = 5) or 29 mm (n = 3) was placed inverted in the tricuspid position after the valsalva sinuses were scalloped. Interrupted 4-0 polypropylene sutures were used between the tricuspid valve annulus and the sewing ring. The struts equivalent on the stentless valve were anchored to the septal, anterior and posteroinferior wall of the right ventricle using 5-0 PTFE pledgeted sutures. Hospital survival was 100% and mean hospital stay was 12.5 days (3 to 18 days). Intraoperative and follow-up echocardiograms revealed no stenosis or insufficiency. Mean follow-up was 17.2 months (1–38 months). There were 3 late deaths due to continued IV drug use (n = 2) and end-stage renal failure (n = 1). This is a novel surgical alternative for a very high risk population. Potential advantages over current options include minimization of blood contact with nonbiological surfaces, preservation of annular motion, freedom from anticoagulation, and a theoretical lower rate of calcification.