Echocardiographic Analysis of an Extracellular Matrix Tricuspid Valve

(Echocardiography 2014;31:E264–E266)Key words: CorMatrix, tricuspid valve, extracellular matrix graft, bioprosthetic valve, echocardiogra-phy, three-dimensional echocardiographyA 26-year-old woman with the diagnosis of adysplastic tricuspid valve was referred for surgicalcorrection due to increasing frequency of dysp-nea on exertion and presyncopal symptoms.Preoperative transthoracic echocardiogram doc-umented severely dilated right-sided chambersand severe tricuspid regurgitation (movie clipS1). The patient was clear that if a repair wasunsuccessful, she did not want a mechanicalvalve replacement.In the operating room, preoperative trans-esophageal echocardiography (TEE) (Vivid I, GEHealthcare, Wauwatosa, WI, USA) again demon-strated severe tricuspid regurgitation (movie clipS2). Initial attempts at repair with closure of mul-tiple leaflet fenestrations as part of performing amodified cone repair and then additionallydownsizing the annulus with a 36-mm tricuspidvalve annuloplasty ring were attempted but ulti-mately failed due to abnormal anterior leafletattachment to the dilated right ventricular (RV)free wall. A custom-made 34-mm extracellularmatrix cylinder valve (ECM-CV; CorMatrix Car-diovascular, Roswell, GA, USA) was used forreplacement. The cylinder valve was constructedfrom a single sheet of ECM fashioned into a cylin-der with a valve height of 1.5 times that of thediameter. It was sewn in circumferentially at theannulus and tacked with pledgeted suture to theRV septum, the RV free wall (there was no ante-rior papillary muscle and the moderator bandwas too remote) and the true posterior papillarymuscle. TEE showed no tricuspid regurgitation inone view (movie clip S3, Fig. 1) and moderateregurgitation in another view (movie clip S4,Fig. 2). Thus, the mechanism of regurgitationwas not entirely clear. Three-dimensional (3D)images clearly showed the mechanism ofregurgitation was through a central coaptationpoint and not due to another mechanism (movie