Totally thoracoscopic beating-heart tricuspid valve repair 30 years after Ebstein’s anomaly surgery: a case report and literature review

Ebstein’s anomaly is a rare congenital malformation of the tricuspid valve that frequently progresses to severe tricuspid regurgitation and right-sided heart failure. Although early surgical repair can provide durable clinical improvement, late recurrent tricuspid regurgitation is not uncommon and may require technically challenging reoperation. In this setting, minimally invasive thoracoscopic beating-heart repair may offer an alternative to redo sternotomy, particularly for high-risk patients. A 50-year-old woman with congenital tricuspid valve disease had previously undergone De Vega annuloplasty for Ebstein’s anomaly at age 19. After more than three decades of clinical stability, progressive exertional dyspnea (New York Heart Association class III), abdominal distension, and bilateral leg edema developed. Evaluation demonstrated massive right atrial enlargement, severe tricuspid regurgitation, preserved left ventricular systolic function, and findings consistent with congestive hepatopathy. Following multidisciplinary evaluation, redo tricuspid valve repair was performed through a totally thoracoscopic right-sided approach using femoro-femoral cardiopulmonary bypass on a beating heart. The anterior and posterior leaflets were mobilized and augmented with a bovine pericardial patch to create a cone-like leaflet configuration, and a 30-mm annuloplasty ring was implanted. Intraoperative transesophageal echocardiography demonstrated trivial residual tricuspid regurgitation. Recovery was uneventful, and the patient was discharged on postoperative day 10. At 3-month follow-up, functional capacity improved, and echocardiography showed mild tricuspid regurgitation with reduced right-sided chamber dimensions. At the latest follow-up, 20 months after surgery, moderate residual tricuspid regurgitation persisted, while right-sided chamber dimensions remained reduced (right atrial transverse diameter, 64 mm; right ventricular transverse diameter, 44 mm). Chest radiography also showed persistent cardiomegaly, although it remained improved compared with the preoperative study. This case shows that totally thoracoscopic beating-heart tricuspid valve re-repair can be technically feasible in selected patients with late recurrent tricuspid regurgitation after prior Ebstein’s anomaly surgery. In this patient, early postoperative improvement was substantial, although extended follow-up demonstrated partial loss of the initial echocardiographic benefit, highlighting the need for continued surveillance and cautious interpretation of long-term durability.