Downloaded from http://journals.lww.com/anesthesia-analgesia by BhDMf5ePHKbH4TTImqenVAHxkFJp/XpPk1L/H3vMGwqMxG9jwOd8eJPG+b4DlKuAX44qu/vwzmc= on 07/30/2018 30 www.anesthesia-analgesia.org January 2015 • Volume 120 • Number 1 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, left- ward 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 leafet malco- aptation. 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 val- vular reinfection, the surgical plan was for reconstruction of the TV using CorMatrix ® (CorMatrix Cardiovascular Inc., Roswell, GA to facilitate native tissue regrowth. After induc- tion of anesthesia and tracheal intubation, a transesophageal echocardiogram (TEE) was performed (X7-2t transducer; Philips Healthcare, Andover, MA). The 2-dimensional mid- esophageal (ME) 4-chamber view with rightward probe rotation revealed right atrial and RV dilatation with mal- coaptation of the TV leafets, severe TR (vena contracta 1.4 cm), and leftward bowing of the interatrial septum (Video 1, Supplemental Digital Content 1, http://links.lww.com/ AA/B20). The remainder of the TEE examination was unre- markable. Before incision, the surgical team requested mea- surements 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 fat CorMatrix sheet into a 3-dimensional, conical shape accounting for the patient’s annular diam- eter and distance from the annulus to the papillary mus- cle 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 leafets. The CorMatrix sheet Copyright © 2014 International Anesthesia Research Society DOI: 10.1213/ANE.0000000000000483 From the Department of Anesthesiology, Baystate Medical Center, Springfeld, Massachusetts, Tufts University School of Medicine, Boston, Massachusetts. Accepted for publication August 4, 2014. Funding: No funding. The authors declare no conficts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (www.anesthesia-analgesia.org). Reprints will not be available from the authors. Address correspondence to Adam C. Adler, MD, MS, Department of Anes- thesiology, Baystate Medical Center, 759 Chestnut St., Springfeld, MA 01199. Address e-mail to adamcadler@gmail.com. Use of Transesophageal Echocardiography for CorMatrix®-Based Tricuspid Valve Repair in a Patient with Recurrent Endocarditis Adam C. Adler, MD, MS, Vatsala Tewari, MD, and Frederick Conlin, MD ECHO ROUNDS E Figure 1. A, Preoperative 2-dimensional midesophageal 4-cham- ber view with right rotation identifying the tricuspid valve (TV) annular diastolic dimension (arrow). B, Preoperative 2-dimen- sional ME 4-chamber view with right rotation identifying the dis- tance of the TV lateral annulus to the papillary muscle during diastole (arrow). C, Transgastric RV infow/outfow view high- lighting the tricuspid valve annular diastolic dimension (arrow). RA = right atrium; LA = left atrium; RV = right ventricle; LV = left ventricle.