MVR + TV repair

Rathiga1*, Sripreethi2, Hemalatha3, Jayamenon4

1ICU Incharge, Kauvery Hospital, Heart City, Trichy, Tamil Nadu

2Nurse Educator, Kauvery Hospital, Heart City, Trichy, Tamil Nadu

3Assistant Nursing Superintendent, Kauvery Hospital, Heart City, Trichy, Tamil Nadu

4 Nursing Superintendent, Kauvery Hospital, Heart City, Trichy, Tamil Nadu

*Correspondence

Abstract

Mitral Valve Replacement (MVR) with concomitant Tricuspid Valve (TV) repair is an open-heart surgery procedure. During the operation, the heart stopped, and a heart-lung bypass machine takes over. The surgeon replaces the damaged mitral valve and reshapes or reinforces the tricuspid valve annulus to treat leaking and prevent future heart failure.

Many patients with mitral valve disease also develop functional Tricuspid Regurgitation (TR). If left untreated, TR can progress and cause right-sided heart failure. Research shows that correcting the tricuspid valve at the same time as an MVR is a safe and reproducible way to decrease TR severity, reduce right-ventricle dimensions, and improve overall clinical outcomes.

Key words: Mitral Valve Replacement (MVR); Tricuspid Valve (TV) repair; Mitral valve disease; Tricuspid regurgitation (TR); Open-heart surgery; Heart valve surgery; Cardiac surgery; Heart failure; Valve annuloplasty; Clinical outcomes.

Introduction

MVR (Mitral Valve Replacement) and TV (Tricuspid Valve) repair are surgical procedures performed on the left and right sides of the heart, respectively. Together, they are used to fix malfunctioning valves that allow blood to leak backward or restrict healthy blood flow. Concomitant TV repair performed during MVR has been shown to reduce the severity of tricuspid regurgitation, improve right ventricular function.

Case presentation

69 Year old male know case of RHD, had complaints of dyspnea and abdomen distension for 5 days for which he initially went to tennur kauvery, where he was diagnosed as right massive pleural effusion for which pigtail drainage of pleural effusion (11/06/2026) and ascitic tapping done he was diagnosed to have rheumatic heart disease with severe MR, moderate MS, severe TR, severe PAH, moderate AR. Preoperative CAG was done on 05/06/2026, which showed normal coronaries and advised for MVR+ TV repair hence came here for further management. After pre-op evaluation done for surgery now patient admitted for DVR + TV repair.

History of past illness

Medical history

  • Known case of systemic hypertension 8 years
  • Known case of rheumatic heart disease – 8 years
  • Known case of COPD – 6 months

Surgical history: Hernioplasty is done. (20 years back)

On examination

Patient conscious, oriented

Temp98.0 F
PR90 b/min
RR20 b/min
CVSS1S2+
RSClear.
P/ASoft
BP120/70mmhg
SpO295% at RA
Height173cm
Weight71kg

Preop medications

DrugDoseFrequency
Inj.pantop40mgOD
Inj.dytor--
Tab.cardivas3.125 mgBD
Tab.isolazine20/37.5 mgBD
Tab.dolo650 mgSOS
Tab.ursocol300 mgBD
Syr.sucrafil10mlTDS
Syr.cremaffin10mlOD
Liquid paraffin lia--

Pre-op Investigation

Hb15.2g/dl
Urea57mg/dl
Creatinine1.1mg/dl
Blood groupingB positive
SerologyNegative

Other Investigation

Carotid and vertebral Doppler

Echo

Left Lower Limb Doppler

Right Lower Limb Doppler

ECG

Diagnosis

  • Rheumatic heart disease
  • Severe MR
  • Moderate MS
  • Severe TR
  • Severe PAH
  • Moderate AR
  • Normal LV
  • T2DM
  • Right Massive pleural effusion
  • S/p . Pigtail catheter insertion & Removed on – (04/06/2026 – 11/06/2026)

Plan :DVR +- TV REPAIR

Surgery name: MVR ( 27 MM bioprosthetic mitral valve) + TV repair.

Procedure

  • Under ETGA standard median sternotomy
  • Inverted T – shaped pericardiotomy
  • Patient heparinized ACT above 480sec
  • SVC, IVC Ao purse string taken AO Bicaval cannulation done. CPB instituted
  • Aorta cross clamped cold blood delnido cardioplegia given through root. Heart arrested in distole
  • RA opened. Septum opened
  • AML + PML thickened Commissures fused
  • AML excised into PML partially preserved 2-0 ethibond plegeted sutures taken around the annulus. Valve sized to 27mm Bioprosthetic mitral valve replacement done valve tested ok. Septum closed
  • Tricuspid valve inspected leaflets good morphology annulus dilated 2-0 ethibond sutuers taken around the annulus plegetted sutures. Devega repair done valve tested ok. RA closed in two layers
  • Patient rewarmed. Hot shot given
  • Heart started to contract
  • Patient came off bypass in stages
  • Protamine followed by sequential decannulation
  • Hemostasis ensured
  • Routine sternal closure
  • Wound closed in layers

Outcome

Open-heart surgery for Mitral Valve Repair (MVR) and Tricuspid Valve (TV) repair has highly successful outcomes. It typically resolves severe regurgitation (leaking), significantly improves quality of life, and restores near-normal life expectancy if performed before irreversible heart damage occurs

Management

Medical Management

  • Anticoagulant Therapy: If the patient receives a mechanical MVR, long-term anticoagulation (e.g., Warfarin) is required to prevent valve thrombosis. Nurses must monitor International Normalized Ratio (INR) levels closely.
  • Inotropes & Vasopressors: Administer medications like Dobutamine, Milrinone, or Norepinephrine as prescribed to support myocardial contractility and blood pressure.
  • Pain Management: Provide adequate analgesia. Managing post-operative sternal pain is critical so the patient can breathe deeply and cough effectively.

Surgical Management

  • Access & Bypass: The surgeon performs a sternotomy (opening the chest bone) or a minimally invasive incision. You are placed on a cardiopulmonary bypass machine (heart-lung machine) so the heart can be safely stopped.
  • Mitral Valve Management: Surgeons try to perform a Repair using techniques like removing excess tissue, shortening supporting cords, or using an annuloplasty ring. If the valve is too calcified or damaged, they perform a Replacement.
  • Tricuspid Valve Management: Tricuspid repair is very common during left-sided heart surgery (like MVR). Surgeons will tighten the leaking valve to restore proper blood flow

Post-Operative Management & Recovery

  • Hospital Stay: You will typically spend 2 to 3 days in the Intensive Care Unit (ICU) followed by 4 to 7 days in a standard hospital ward.
  • Medication: Post-surgery, you will require medications to manage heart rhythm, prevent blood clots (anticoagulants), and manage blood pressure. If a mechanical valve is used, lifelong blood thinners are required.
  • Recovery Timeline: Full recovery typically takes 4 to 8 weeks, though it may take longer for a full return to normal activity. Cardiac rehabilitation is standard practice to safely rebuild strength.
  • Cardiac Rehabilitation: Doctors highly recommend entering a monitored cardiac rehab program to safely regain your strength, endurance, and cardiovascular health.

Nursing management

Mitral Valve Replacement/Repair (MVR) and Tricuspid Valve (TV) Repair requires rigorous, multi-system monitoring during open-heart surgery recovery. The primary goals are to maintain hemodynamic stability, optimize oxygenation, prevent thromboembolism, and manage complications related to the cardiopulmonary bypass.

  • Hemodynamic Monitoring: Continuously monitor arterial blood pressure, central venous pressure (CVP), and pulmonary artery pressures. Assess for hypotension (indicating poor cardiac output or bleeding) and hypertension (which stresses suture lines).
  • Respiratory & Airway Management: Maintain mechanical ventilation in the immediate post-operative phase. Once extubated, prioritize aggressive pulmonary hygiene: encourage coughing, deep breathing, and the use of an incentive spirometer to prevent atelectasis and pneumonia.
  • Fluid & Electrolyte Balance: Strictly monitor intake and output (I&O) and daily weights. Maintain tight control over serum electrolytes, particularly potassium (K⁺) and magnesium (Mg²⁺), as imbalances frequently trigger life-threatening cardiac dysrhythmias.
  • Chest Tube Management: Monitor chest tube drainage for color, consistency, and volume (report outputs >100 ml/hr). Ensure patency by checking for tidaling and bubbling; milk or strip the tubes only per unit protocol to prevent clots.
  • Neurological Assessments: Conduct frequent neuro-checks to quickly identify signs of a stroke or neurological deficit, which is a major risk during or following open-heart surgery.

Discharge

DrugDoseFrequency
Tab. Digoxin0.25MGOD (5/7)
Tab. Thyronorm25MCGOD
Inj. Cefactam ds1.5GMBD
Inj. Pantop40MGOD
Tab. UltracetTDS
Tab. Dytor10MGTDS
Tab. Alprax0.5MGOD
Tab. Dulcolax5MGOD
Tab. Ursocol300MGOD
Tab. Colchicine0.5MGBD
Tab. Nodosis gst500MGTDS
Tab. Natrise15MGBD
Tab. Wymada25MGBD
Syp. Mucolite10MLTDS
Syp. Ulgel10MLTDS
Syp. Duphalac10MLOD
Neb. Duolin-QID
Neb. Budecort-TDS
Neb. Mucomix-BD

Infection Control: Adhere to strict aseptic technique for all invasive lines and the surgical site. Monitor the sternal incision and donor sites for redness, warmth, or purulent drainage.

 

Conclusion

Medical literature overwhelmingly concludes that performing a concomitant tricuspid valve (TV) repair alongside mitral valve (MV) surgery whether a repair or replacement (MVR)is a highly safe, durable, and beneficial strategy. It successfully reduces tricuspid regurgitation (TR) without significantly increasing operative risks, postoperative complications, or mortality.

Reference

  1. M., & Bonow, R. O. (2022). Braunwald’s heart disease: A textbook of cardiovascular medicine (12th ed.). Elsevier.
  2. Mitral valve disease & surgery: Chapter 76 (approximately pp. 1575–1615, edition dependent).
  3. Sellke, F. W., del Nido, P. J., & Swanson, S. J. (Eds.). (2024). Sabiston and Spencer surgery of the chest (10th ed.). Elsevier.
  4. Tsang, T. S. M., & Adams, D. H. (Eds.). (2021). Cardiac surgery in the adult (5th ed.). McGraw-Hill Education.
  5. Mahboobi, S. K., Sharma, S., & Ahmed, A. A. (2026). Tricuspid valve repair. In StatPearls. StatPearls Publishing.
  6. Vaidya, Y., Sharma, S., & Widrich, J. (2026). Mitral valve repair. In StatPearls. StatPearls Publishing.

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