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Cardiovascular Anesthesiology: Echo Rounds

Use of Transesophageal Echocardiography for CorMatrix®-Based Tricuspid Valve Repair in a Patient with Recurrent Endocarditis

Adler, Adam C. MD, MS; Tewari, Vatsala MD; Conlin, Frederick MD

Author Information
doi: 10.1213/ANE.0000000000000483

A 42-year-old female with a longstanding history of heroin use and polymicrobial endocarditis arrived with shortness of breath and a feeling of choking while supine. A transthoracic echocardiogram revealed right atrial enlargement, right ventricle (RV) dilatation, leftward bowing of the interatrial septum, and severe tricuspid regurgitation (TR). Over the preceding 18 months, she had multiple episodes of endocarditis with tricuspid valve (TV) vegetations, resulting in wide-open TR from leaflet malcoaptation. She was noncompliant with antibiotic therapy and was lost to follow-up. Written consent was obtained from the patient for publication of this report.

Due to the patient’s history of drug use and risk for valvular reinfection, the surgical plan was for reconstruction of the TV using CorMatrix® (CorMatrix Cardiovascular Inc., Roswell, GA to facilitate native tissue regrowth. After induction of anesthesia and tracheal intubation, a transesophageal echocardiogram (TEE) was performed (X7-2t transducer; Philips Healthcare, Andover, MA). The 2-dimensional midesophageal (ME) 4-chamber view with rightward probe rotation revealed right atrial and RV dilatation with malcoaptation of the TV leaflets, severe TR (vena contracta 1.4 cm), and leftward bowing of the interatrial septum (Video 1, Supplemental Digital Content 1, The remainder of the TEE examination was unremarkable. Before incision, the surgical team requested measurements of the native valve to be performed. Using the 2-dimensional ME 4-chamber view with right rotation, we measured the TV annular diameter (38 mm), and distance from the lateral annulus to the papillary muscle in diastole (43 mm) (Fig. 1). The surgeon used these measurements to construct the flat CorMatrix sheet into a 3-dimensional, conical shape accounting for the patient’s annular diameter and distance from the annulus to the papillary muscle base. The surgeon used the diastolic annular diameter to calculate the TV circumference as 2π(diameter/2) or 119.4 mm. Circumference was divided by 3 to create the horizontal dimensions of the trifold corresponding to the anterior, posterior, and septal leaflets. The CorMatrix sheet dimensions were 120 mm horizontally and 50 mm vertically (Fig. 2). The surgeon calculated the CorMatrix vertical dimension multiplying the diastolic annular diameter by 1.3. Midline sternotomy was performed followed by initiation of cardiopulmonary bypass (CPB). The tricuspid annulus was measured using an M3 sizer followed by native valve excision. The CorMatrix was rehydrated in saline and then sutured onto the TV annulus and base of the papillary muscles. The excess CorMatrix material in the vertical dimension allows for upward billowing during systole like a wind-sock, providing valvular competency. The RV was insufflated with saline to demonstrate valve competency. Postoperative TEE demonstrated the reconstructed valve to be in satisfactory position with trace TR and no flow acceleration with color Doppler (Video 2, Supplemental Digital Content 2, Recovery was uneventful, and the patient was discharged on postoperative day 4.

Figure 1
Figure 1:
A, Preoperative 2-dimensional midesophageal 4-chamber view with right rotation identifying the tricuspid valve (TV) annular diastolic dimension (arrow). B, Preoperative 2-dimensional ME 4-chamber view with right rotation identifying the distance of the TV lateral annulus to the papillary muscle during diastole (arrow). C, Transgastric RV inflow/outflow view highlighting the tricuspid valve annular diastolic dimension (arrow). RA = right atrium; LA = left atrium; RV = right ventricle; LV = left ventricle.
Figure 2
Figure 2:
A, Flat CorMatrix® sheet during valve construction. The top part of the sheet (red arrow) represents the portion that will be sewn to the annulus. The A, S, P listed at the bottom of the CorMatrix sheet correspond to the regions that will be sutured to each papillary muscle base (anterior, septal, and posterior) (yellow arrow). The sheet measures 120 mm in the horizontal plane and 50 mm in the vertical. B, Intraoperative image showing the CorMatrix sutured to the tricuspid annulus. Figure 2B reproduced with permission.


The number of IV drug-induced cases of endocarditis has been increasing due to a growing number of people using IV drugs. Replacement with bioprosthetic or mechanical valves in IV drug users carries a high risk of recurrent endocarditis. Recurrent endocarditis after TV repair carries lower rates of tricuspid insufficiency compared with replacement or excision.1

The importance of echocardiography in the diagnosis and treatment of infective endocarditis has become exceedingly recognized and serves as major criteria in diagnosis. Intraoperatively, TEE may be used to guide the surgical dissection and for identification of dehisced areas or abscess formation.2 Common views for TV imaging include ME 4-chamber (0°), ME RV inflow–outflow (60°–90°), ME RV inflow/coronary sinus window (100°–120°), and transgastric (TG) RV inflow–outflow views (100°–145°). Maslow et al.3 revealed the best view for measurement of TV annular diastolic distance to be the TG RV inflow–outflow because this measurement best correlates with intraoperative surgical measurement. In our case, the tricuspid annular measurements made in ME 4-chamber view (3.79 cm) were close to those in the TG RV inflow–outflow view (3.97 cm). Regurgitant jets measured larger in the ME 4-chamber view and ME RV inflow–outflow view compared with ME coronary sinus view with the smallest measured jets in the TG RV inflow–outflow view. Regurgitant jet dimensions should be measured in multiple views to ensure accuracy. Thus, TV annular distance should ideally be measured in the TG RV inflow–outflow view and TR jet dimensions measured from ME views.3

CorMatrix is an extracellular matrix produced from porcine small intestine submucosa. It functions as an acellular bioscaffold for native tissue regeneration. Structural components include proteins (collagen, elastin), adhesion glycoproteins (fibronectin, laminin), glycosaminoglycans, proteoglycans, and matricellular proteins.a Application of CorMatrix in cardiac surgery is relatively new. CorMatrix has been used successfully for adult cardiac tissue repair, including its use as a patch for an ascending aortic ulceration, as a myocardial patch for repair of large left ventricular false aneurysm as well as patchwork for other intracardiac structures.4,5 Gerdisch et al.6 report a retrospective study of 19 patients having undergone successful mitral valve repairs using CorMatrix with median follow-up of 10.8 months and extending as far as 48 months. The longer follow-up demonstrates CorMatrix to be devoid of significant inflammatory response or significant calcification.6,7 In both animals and humans, native tissue regeneration is reported to occur at 3 to 4 months after CorMatrix implantation.5,6 CorMatrix has been used for pericardial closure and as a substitute for an autologous pericardial patching due to its increased tensile strength compared with native tissue.4 There is a single case report identifying the similar use of CorMatrix for TV reconstruction after endocarditis in which similar dimensions were used, specifically a valve length of 50 mm.2

Measurement of the annular to papillary distance in diastole (43 mm in this case) by TEE as described above provides the largest distance as the ventricle is most distended. In RV systole, when the CorMatrix valve competence is required, this distance is reduced such that upsizing the largest dimension by 1.3 (50 mm in the vertical plane in this case) provides the redundancy necessary for the systolic billowing that restricts regurgitant flow. In the aforementioned case report, TEE detected early dehiscence of the distal end of the graft, allowing repair before separation from CPB.2 The echocardiographer should be assessing the neo-valve for systolic billowing and competency, with tolerance for mild TR and absence of significant stenosis or surgically correctable issues before CPB separation. CorMatrix-based valves display echogenicity similar to that of native myocardial tissue (Fig. 3). One-year follow-up transthoracic echocardiogram showed no appreciable change in appearance or calcification of the CorMatrix valve (Fig. 4).b Potential benefits of CorMatrix repair include: decreased risk of reinfection compared to mechanical prostheses, avoidance of implanted thrombogenic material, and decrease in reoperative rates although a larger cohort is needed to fully assess the benefits with this new approach. In our case, due to the patient’s recurrent IV drug use, it was decided to proceed with CorMatrix reconstruction theorizing that native tissue re-growth will be supported over the bioscaffold decreasing the risk of reinfection compared with valve replacement. E

Figure 3
Figure 3:
A, Two-dimensional midesophageal (ME) 4-chamber view with right rotation identifying the CorMatrix® valve during systole with expected upward billowing. B, ME 4-chamber view, right rotation and applied color flow Doppler, identifying the CorMatrix valve during systole with satisfactory competency and trace tricuspid regurgitation (red arrow).
Figure 4
Figure 4:
Transthoracic echocardiography 1 year after CorMatrix® valve replacement. Modified parasternal long-axis, right chamber view showing the appearance of CorMatrix valve in (A) diastole and (B) systole. (C) Apical 4-chamber view during systole revealing the expected wind-sock appearance of the CorMatrix.

Clinician’s Key Teaching Points

By Kent H. Rehfeldt, MD, Donald Oxorn, MD, and Martin J. London, MD

  • Prosthetic valve endocarditis is a difficult management problem, particularly in IV drug users. CorMatrix™ (CorMatrix Cardiovascular Inc., Roswell, GA) is an acellular, bioscaffold material that has been used for the customized surgical repair of a variety of cardiac structures, including ascending aorta, the interventricular septum, and the mitral and tricuspid valves. It facilitates native tissue ingrowth and, when used for valve reconstruction, may decrease the risk of subsequent endocarditis compared with prosthetic replacement.
  • Intraoperative transesophageal echocardiography (TEE) is essential in surgical planning before valvular reconstruction using CorMatrix. In particular, TEE provides key diastolic measurements such as the annular diameter and the annulus to papillary muscle distance that are required to properly construct a neovalve; there must be adequate tricuspid inflow dimensions, and sufficient redundancy to allow an adequate zone of coaptation.
  • In this case of recurrent tricuspid valve endocarditis in an IV drug user, the midesophageal (ME) 4-chamber and transgastric (TG) right ventricle (RV) inflow/outflow views were used to measure the diastolic tricuspid annular diameter, and the ME 4-chamber view was used to measure the diastolic distance from the lateral annulus to the papillary muscle. After reconstruction, TEE showed the expected systolic billowing of CorMatrix material into the right atrium that is indicative of adequate leaflet coaptation.
  • Experience with tricuspid valve reconstruction using CorMatrix material is currently limited to 2 reports, although it has been incorporated in a number of mitral repairs. A variety of TEE views may be used to obtain tricuspid annular measurements, including the ME 4-chamber, the ME RV inflow-outflow, and the TG RV inflow views, with the latter correlating best with surgical measurements. Tricuspid annular dimensions may be more accurately measured using 3-dimensional imaging, though the application of 3-dimensional imaging to tricuspid reconstruction has not been reported.


Name: Adam C. Adler, MD, MS.

Contribution: This author helped design the study, conduct the study, analyze the data, and write the manuscript.

Attestation: Adam C. Adler approved the final manuscript.

Name: Vatsala Tewari, MD.

Contribution: This author helped design the study, conduct the study, analyze the data, and write the manuscript.

Attestation: Vatsala Tewari approved the final manuscript.

Name: Frederick Conlin, MD.

Contribution: This author helped design the study, conduct the study, analyze the data, and write the manuscript.

Attestation: Frederick Conlin approved the final manuscript.

This manuscript was handled by: Martin J. London, MD.


a CorMatrix® Cardiovascular, Inc.: CorMatrix® ECM® Bioscaffold: Accessed November 19, 2013.
Cited Here

b One-year follow-up TTE imaging from the first patient who underwent CorMatrix reconstruction of the TV at our institution.
Cited Here


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