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Technic of tricuspid annuloplasty
Technic
of Tricuspid
Annuloplasty
R. W. M. FRATER, M.B., CH.B., F.R.c.s., Bronx, New York
Fromthe Departmentof Surgery, Albert Einstein College of Medicine, New York, New York. of the correction of triinsufficiency as a part of surgical repair in cases of multivalvular acquired heart disease has been increasingly recognized [I-3]. When concomitant tricuspid insufficiency is ignored during mitral and/or aortic valve replacements or repairs, the early postoperative management is often difficult and raised venous pressure, hepatomegaly, ascites, and edema may continue to plague the patient for as long as a year after surgery. Many surgeons have advocated tricuspid valve replacement in this situation [3,4]. However, there is no question that annuloplasty can be used successfully in many cases and that some surgeons do in fact use it [I]. The technic described in detail herein has worked well for me.
T cuspid HE
IMPORTANCE
INDICATIONS
disease. The pulmonary hypertension commonly present in these cases persists for many months after surgery and, as with the mitral valve, insufficiency due to “ring” dilatation can be self-aggravating. SURGICALANATOMYOF THE TRICUSPID VALVE The features of tricuspid valve anatomy relevant to this article can be briefly presented. The orifice of the tricuspid valve is semilunar in shape because of the way the right ventricle is wrapped around the left. With gross right ventricular enlargement it becomes more circular. The line of attachment of the cusps is at the junction of ventricular and atria1 walls anteriorly and laterally. However, medially and posteriorly the septal cusp is attached not to the junction of ventricular and atria1 septa, but deeper than this to the right hand surface of the ventricular septum. (Fig. 1.) At the posterior end of the septal attachment, on the atria1 side, is the orifice of the coronary sinus; at the anterior end on the ventricular side is the membranous part of the ventricular septum, Between these two sites the conducting system is potentially in danger. Where the septum meets the right ventricular wall anteromedially, there is a close relationship to the parts of the noncoronary and right coronary sinuses of Valsalva of the aortic root. The right circumflex coronary artery lies in the atrioventricular groove and is thus closely related to that part of the valve attached to the ventricular wall. (Fig. 2 and 3.) Along the line of attachment a fibrous “ring” is not as easy to define as it is around the mitral valve although it can indeed be identified. There are, of course, three main cusps. (Fig. 4.) The septal cusp, shaped like a part of a semicircle, has one anatomic feature of importance: a number of third order chordae tendineae that join the body of the cusp di-
FOR SURGERY
The presence of raised venous pressure with prominent systolic jugular pulsation and an enlarged pulsating liver indicates significant tricuspid insufficiency whether or not accompanied by typical auscultatory findings. When, after a period of normal medical management, this evidence of gross tricuspid insufficiency persists, then surgery on the tricuspid valve should be a planned part of the procedure. The persistence of tricuspid insufficiency despite maximal medical management is no indication of the pathologic disorder that will be found. Indeed, more often than not it will be of the so-called “functional” variety with a dilated “ring” and cusps minimally affected by the rheumatic process. It should be reiterated that the presence of this form of tricuspid insufficiency does not presage a rapid resolution after correction of mitral or aortic valve 482
American Journal of Surgevy
483
Tricuspid Annuloplasty
FIG. 1. Autopsy specimen showing both atrioventricular valves from the atria1 aspect. S marks the bared ventricular septum and A is the exposed aortic root. The mitral valve is below the septum in the illustration and the tricuspid valve above it; s, a, and 1 are the septal, anterior, and lateral cusps of the tricuspid valve. Commissural areas are evident between septal and anterior and anterior and lateral cusps; c designates the large lateral commissural area FIG. 2. Normal valve closed. A, site of aortic root; C, coronary vessels in close proximity; M, membranous deep to cusp here; CS, coronary sinus; B, bundle of His; s, a, and 1, septal, anterior, and lateral cusps.
septum
FIG. 3. Dilated tricuspid valve closed.
rectly to the septum. The first order chordae tendineae also for the most part arise directly and separately from the septum. This chordal pattern makes advancement of this cusp extremely difficult. The other two main cusps have beenvariously named. I have chosen to call them anterior and lateral since whatever the rotation of the heart, these descriptions remain apt. These cusps are deeper than the septal cusp but because, as on the left side, the plane of the atrioventricular orifice is oblique, the free edges of all three cusps descend to the same depth in the ventricle. Their free edges are supported on each side by first order chordae tendineae with a short central bare portion and away from the edges they are supported by second order chordae tendineae in exactly the same way as the anterior and posterior cusps of the mitral valve are supported [5]. And as the mitral valve has its main cusps separated but still bridged and connected by commissural tissue, so also are there considerable lengths of commissural tissue between the three cusps of the tricuspid valve. Two of the commissural areas are in the angles between the septum and the ventricular wall, while the third is of course situated anterolaterally between the anterior and lateral cusps. Of the three commissural areas, that between septal and lateral cusps occupies the greatest proportion of the circumference of Vol. 113, April 1967
the valve and that between septal and anterior cusps the least. It is common for particularly the anterior and lateral commissural tissue to have sufficient depth to be regarded as commissural cusps. At the anterior commissure this “cusp” frequently takes the form of a triangular piece of tissue with a large first order chorda inserted at its apex and supported on each side by branches from the first order chordae tendineae to the main cusps. (Fig. 5.) TECHNIC
OF REPAIR
With the common finding of a dilated ring and relatively normal main cusps, the only suitable operation is annuloplasty. Cusp extension operations in my experience are generally unsuccessful because the cusp tissues are too thin to hold stitches well. Whatever repair is carried out must withstand high pressures for several months since virtually all these patients have considerable pulmonary hypertension, the resolution of which is slow despite complete repair of the left sided lesions. The obvious site for annuloplasty stitches is at the commissures. These must be precisely placed, however, to correct insufficiency in the first place and to hold in the second. From bitter personal experience I know that no amount of buttressing with pledgets of plastic felt or sponge will help improperly placed stitches to produce normal hemodynamic
Frater
4
5
FIG. 4. Tricuspid valve removed with chordae ttndineae and papillary muscles. A, L, S, anterior, lateral, and septal cusps viewed from their ventricular aspects. Note the chordal patterns. LC and LC, lateral commissural cusps; PMC, papillary muscle of the conus. FIG. 5. Technic of annuloplasty. On the left the stitch has been placed precisely at the edges of the cusps. It has been tied at the top and a part of the atria1 wall picked up. On the right the annuloplasty stitch has been covered with atria1 tissue.
function or to maintain it if initially achieved. Bearing in mind the relationships of the valve ring already described, we see that the stitches must be deep enough to encompass such fibrous ring as exists. To be sure of getting a reasonably firm bite, 1 or 2 mm. of valve tissue adjacent to the ring should be taken in the stitch. This is more substantial tissue than the atria1 wall muscle on the proximal side of the ring. To take a greater amount of valve tissue, however, may result in tearing or distortion of cusps. The purpose of the annuloplasty stitches is to bring the three main cusps closer to each other without interfering with their mobility, form, or length. To achieve this the margins of the main cusps must be identified andbrought evenly towards each other. A stitch that accomplishes this most effectively is that used by Wooler et al. for mitral annuloplasty. [6] A No. l-0 silk suture on the smallest available atraumatic needle is passed around the “ring” structures precisely at the edges of the main cusps so that the knot, when tied, presents in the atrium. This stitch must not pass through main cusp tissue. The stitch is completed by pulling atria1 muscle tissue from each side over the first knot and then running it up into the atrium. When this is carried out during mitral annuloplasty, it draws a fold of atria1 wall inwards to act as an extra baffle for the anterior cusp but probably acts also to rein-
force the main stitch. It has been used on the tricuspid side since it has worked well for the mitral side and may well help the stitches to hold although with three cusps it does not have the same effect of producing an extra closing surface. At times the gap between main cusps has stretched too wide for one stitch to close it. More than one must then be used, taking care that they are placed so as to be equidistant from the cusp edges on each side. At the lateral and anterior commissures these stitches will achieve their purpose of bringing the cusps together extremely well. At the medial commissure, however, the tissues deep to the ring are intimately related to the underlying and rather unyielding aorta. As a result it is more difficult to obliterate the commissural area here. Fortunately this is generally the narrowest commissure and seems less important in the process of atrioventricular dilatation that leads to the insufficiency. Indeed, in most cases, after narrowing the anterior and lateral commissural areas, the insufficiency appears to be corrected. ORGANIC TRICUSPID INSUFFICIENCY
Organic tricuspid incompetence is a more difficult problem. In my experience the pathologic disorder is virtually always the same. The valve is in the form of a diaphragm with loss of identity of separate cusps and a relaAmerican Journal of Suvgery
Tricuspid some\vhat reduced orifice. The usually a little thickened but the In&n substance of the cusps is thin and pliable. The chordae tcndincac are unthickened and 1111fu5eti although they may appear more crcl\vcled than norlnal. The commissural areas ;Lrc’ obliterated but there is no separable line (11‘fusion, \uch as i\ evident in cases of mitral \tcnosis. It is as if there has been a concentric shortening of the free edge of the valve, which is maximal in the commissural areas, together \vith some shortenin g of the main cusps. This ‘;cirves to lessen the difference in depth between the cusps and the commissural tissue and to shorten the length IJt‘ the tissue so that in the most extreme form the valve is converted into a thill and still pliable washer, with no distinct cusps and with a central orifice that is both inoderately stenotic and freely incompetent. The sites usually used for the annuloplasty stitches are not in evidence and indeed shortvning the ring at several points merely crimps and increases the stenosis the “diaphragm” without producing a valve with cusps that can meet each other properly. Cutting into \vhat is left of the commissural areas helps \.cry little since more than a very shallow cut gets out into cusp tissue which is unsupported by chordae tenclineae and is therefore incompetent [5]. If the degree of stenosis is tolerable, pericardial or homograft extension of one half of the cusp tissue can work very 1~41 171. By contrast to the normal cusp tissue oithe “functionally” incompete;t valve, that cd the organically diseased valve, although Ijliable, is thick enough to hold stitches. Nevertheless, in the presetIce of organic incompetence it is often impossible. despite the presence of lnuch pliable cusp tissue, to perform an adecjuate plastic repair. ti\-cI!,
fiseci.
l’rc‘c‘ edges
are
KESLXTS
Six patients have been followed up for from six to eighteen months after tricuspid annuloplasty for hemodynamically severe tricuspid insufficiency. (Annuloplasty stitches have been used in a number of other patients not included in this series, who had moderate or minor degrees of tricuspid insufficiency.) .I11 the patients had surgery on the mitral valve and two had aortic valve replacements as well. All were in class IV functionally. The
Annuloplast
y
tnean
pulmonary arterial pressure for thehe patients ranged between 35 and li.? mm. Hg. Five had pure incompetence tluc to dilated valvt ririgs and one had sonic organic changes as well. In this last patient a cautious in&ioIl in one commissural area ~~35 used in additiott to the almuloplasty stitches. I’reoperativcly, all the patients had large “I”’ L\XVCS in the jugular pulse and markedly pulsating livers besides the usual evidence of congestive heart failure. Postoperatively, although mean right atria1 pressures were above normal for a ieli days, by the time the patients left the hospital the pressure5 were no longer raised. The “I?” wave in the jugular pulse had disappearctl ant! the hepatic pulsation could no Irqer be detected. No murmurs of tricuspid insuf’licienc\ could be heard. The findings, ha\-c persist&l throughout the follow-up periotl. (he pat&l t requires diuretics to prevent recurrence of ascitc\. Significant tricuspid insuf?iciency accompanying lesions of the mitral and aortic valves produces serious effects if they are not repaired at the same time as the left sided lesions. The technic of tricuspid annuloplasty is described, a procedure which if properly performed is most useful and successful. REFERENCES 1. KAY, J. H., TSUJI, H. K., MASELLI, G. and CA.ZIPAGNA, M. D. Surgical treattncnt of tricuspid insufficiency. .lnn. Skip., 162: 53, l!l65. 2. FRATER. R. W. M.. BARNARD. C. S.. SCHRIRH. \-. Open heart surgery for rhrutnatic tliscaw of t,llr mitral valve. .S. .Ifricnn 211. .I.,38: TX, 1964. 3. LILLEHEt, c. W., GANKOS. I’. c;.. I,E\.Y, M. 1 I'ARCO. R. L.. and WANG, V. \‘alve replacement for tricuspid strnosis or insufficiency asswiatcd witlt mitral valve diseasr. Ci~z6/ation, 33: 3-k. I#% 4. STARR, .I.. HERR, R. H.. WOOD, -1. .\., EI)\YARI)~, M. I... and GRISWOLD. H. E. Tricuspid rcplaccmcnt: clinical rsprrience with the lxx11 V:I!VC, prosthesis. Circulation, 11: 202. 1065. 5. FRATER. R. W. M. Anatomical rulrs for tltc plastic repair of it diseased mitral valve. ?‘hows. 10: -I%%, In&+.
6.
7.
WOOLER. G. H., x1X0x, I’. G. F.. C;RrblSHA\\., \ :\ , and WATSON, I>. h. Experiwces with tltc wpxir of the mitral valve in mitral ittc~n~~petcw.-c. ?‘liow.r. 17: 49. 1%‘~. , I FRATER, R. W. M., BEGHUtS. J and BRO:\Z, 3. I,.. JR. The experimental and clinical USC 01 autoaenous pericardium for the replaccm~~nt ;1t1,1 extension of mitral and tricuspid cusps :t!td clt~~rdae. .I. Cniditmns. Surg., 6: 911, l!x.i.
of Tricuspid
Annuloplasty
R. W. M. FRATER, M.B., CH.B., F.R.c.s., Bronx, New York
Fromthe Departmentof Surgery, Albert Einstein College of Medicine, New York, New York. of the correction of triinsufficiency as a part of surgical repair in cases of multivalvular acquired heart disease has been increasingly recognized [I-3]. When concomitant tricuspid insufficiency is ignored during mitral and/or aortic valve replacements or repairs, the early postoperative management is often difficult and raised venous pressure, hepatomegaly, ascites, and edema may continue to plague the patient for as long as a year after surgery. Many surgeons have advocated tricuspid valve replacement in this situation [3,4]. However, there is no question that annuloplasty can be used successfully in many cases and that some surgeons do in fact use it [I]. The technic described in detail herein has worked well for me.
T cuspid HE
IMPORTANCE
INDICATIONS
disease. The pulmonary hypertension commonly present in these cases persists for many months after surgery and, as with the mitral valve, insufficiency due to “ring” dilatation can be self-aggravating. SURGICALANATOMYOF THE TRICUSPID VALVE The features of tricuspid valve anatomy relevant to this article can be briefly presented. The orifice of the tricuspid valve is semilunar in shape because of the way the right ventricle is wrapped around the left. With gross right ventricular enlargement it becomes more circular. The line of attachment of the cusps is at the junction of ventricular and atria1 walls anteriorly and laterally. However, medially and posteriorly the septal cusp is attached not to the junction of ventricular and atria1 septa, but deeper than this to the right hand surface of the ventricular septum. (Fig. 1.) At the posterior end of the septal attachment, on the atria1 side, is the orifice of the coronary sinus; at the anterior end on the ventricular side is the membranous part of the ventricular septum, Between these two sites the conducting system is potentially in danger. Where the septum meets the right ventricular wall anteromedially, there is a close relationship to the parts of the noncoronary and right coronary sinuses of Valsalva of the aortic root. The right circumflex coronary artery lies in the atrioventricular groove and is thus closely related to that part of the valve attached to the ventricular wall. (Fig. 2 and 3.) Along the line of attachment a fibrous “ring” is not as easy to define as it is around the mitral valve although it can indeed be identified. There are, of course, three main cusps. (Fig. 4.) The septal cusp, shaped like a part of a semicircle, has one anatomic feature of importance: a number of third order chordae tendineae that join the body of the cusp di-
FOR SURGERY
The presence of raised venous pressure with prominent systolic jugular pulsation and an enlarged pulsating liver indicates significant tricuspid insufficiency whether or not accompanied by typical auscultatory findings. When, after a period of normal medical management, this evidence of gross tricuspid insufficiency persists, then surgery on the tricuspid valve should be a planned part of the procedure. The persistence of tricuspid insufficiency despite maximal medical management is no indication of the pathologic disorder that will be found. Indeed, more often than not it will be of the so-called “functional” variety with a dilated “ring” and cusps minimally affected by the rheumatic process. It should be reiterated that the presence of this form of tricuspid insufficiency does not presage a rapid resolution after correction of mitral or aortic valve 482
American Journal of Surgevy
483
Tricuspid Annuloplasty
FIG. 1. Autopsy specimen showing both atrioventricular valves from the atria1 aspect. S marks the bared ventricular septum and A is the exposed aortic root. The mitral valve is below the septum in the illustration and the tricuspid valve above it; s, a, and 1 are the septal, anterior, and lateral cusps of the tricuspid valve. Commissural areas are evident between septal and anterior and anterior and lateral cusps; c designates the large lateral commissural area FIG. 2. Normal valve closed. A, site of aortic root; C, coronary vessels in close proximity; M, membranous deep to cusp here; CS, coronary sinus; B, bundle of His; s, a, and 1, septal, anterior, and lateral cusps.
septum
FIG. 3. Dilated tricuspid valve closed.
rectly to the septum. The first order chordae tendineae also for the most part arise directly and separately from the septum. This chordal pattern makes advancement of this cusp extremely difficult. The other two main cusps have beenvariously named. I have chosen to call them anterior and lateral since whatever the rotation of the heart, these descriptions remain apt. These cusps are deeper than the septal cusp but because, as on the left side, the plane of the atrioventricular orifice is oblique, the free edges of all three cusps descend to the same depth in the ventricle. Their free edges are supported on each side by first order chordae tendineae with a short central bare portion and away from the edges they are supported by second order chordae tendineae in exactly the same way as the anterior and posterior cusps of the mitral valve are supported [5]. And as the mitral valve has its main cusps separated but still bridged and connected by commissural tissue, so also are there considerable lengths of commissural tissue between the three cusps of the tricuspid valve. Two of the commissural areas are in the angles between the septum and the ventricular wall, while the third is of course situated anterolaterally between the anterior and lateral cusps. Of the three commissural areas, that between septal and lateral cusps occupies the greatest proportion of the circumference of Vol. 113, April 1967
the valve and that between septal and anterior cusps the least. It is common for particularly the anterior and lateral commissural tissue to have sufficient depth to be regarded as commissural cusps. At the anterior commissure this “cusp” frequently takes the form of a triangular piece of tissue with a large first order chorda inserted at its apex and supported on each side by branches from the first order chordae tendineae to the main cusps. (Fig. 5.) TECHNIC
OF REPAIR
With the common finding of a dilated ring and relatively normal main cusps, the only suitable operation is annuloplasty. Cusp extension operations in my experience are generally unsuccessful because the cusp tissues are too thin to hold stitches well. Whatever repair is carried out must withstand high pressures for several months since virtually all these patients have considerable pulmonary hypertension, the resolution of which is slow despite complete repair of the left sided lesions. The obvious site for annuloplasty stitches is at the commissures. These must be precisely placed, however, to correct insufficiency in the first place and to hold in the second. From bitter personal experience I know that no amount of buttressing with pledgets of plastic felt or sponge will help improperly placed stitches to produce normal hemodynamic
Frater
4
5
FIG. 4. Tricuspid valve removed with chordae ttndineae and papillary muscles. A, L, S, anterior, lateral, and septal cusps viewed from their ventricular aspects. Note the chordal patterns. LC and LC, lateral commissural cusps; PMC, papillary muscle of the conus. FIG. 5. Technic of annuloplasty. On the left the stitch has been placed precisely at the edges of the cusps. It has been tied at the top and a part of the atria1 wall picked up. On the right the annuloplasty stitch has been covered with atria1 tissue.
function or to maintain it if initially achieved. Bearing in mind the relationships of the valve ring already described, we see that the stitches must be deep enough to encompass such fibrous ring as exists. To be sure of getting a reasonably firm bite, 1 or 2 mm. of valve tissue adjacent to the ring should be taken in the stitch. This is more substantial tissue than the atria1 wall muscle on the proximal side of the ring. To take a greater amount of valve tissue, however, may result in tearing or distortion of cusps. The purpose of the annuloplasty stitches is to bring the three main cusps closer to each other without interfering with their mobility, form, or length. To achieve this the margins of the main cusps must be identified andbrought evenly towards each other. A stitch that accomplishes this most effectively is that used by Wooler et al. for mitral annuloplasty. [6] A No. l-0 silk suture on the smallest available atraumatic needle is passed around the “ring” structures precisely at the edges of the main cusps so that the knot, when tied, presents in the atrium. This stitch must not pass through main cusp tissue. The stitch is completed by pulling atria1 muscle tissue from each side over the first knot and then running it up into the atrium. When this is carried out during mitral annuloplasty, it draws a fold of atria1 wall inwards to act as an extra baffle for the anterior cusp but probably acts also to rein-
force the main stitch. It has been used on the tricuspid side since it has worked well for the mitral side and may well help the stitches to hold although with three cusps it does not have the same effect of producing an extra closing surface. At times the gap between main cusps has stretched too wide for one stitch to close it. More than one must then be used, taking care that they are placed so as to be equidistant from the cusp edges on each side. At the lateral and anterior commissures these stitches will achieve their purpose of bringing the cusps together extremely well. At the medial commissure, however, the tissues deep to the ring are intimately related to the underlying and rather unyielding aorta. As a result it is more difficult to obliterate the commissural area here. Fortunately this is generally the narrowest commissure and seems less important in the process of atrioventricular dilatation that leads to the insufficiency. Indeed, in most cases, after narrowing the anterior and lateral commissural areas, the insufficiency appears to be corrected. ORGANIC TRICUSPID INSUFFICIENCY
Organic tricuspid incompetence is a more difficult problem. In my experience the pathologic disorder is virtually always the same. The valve is in the form of a diaphragm with loss of identity of separate cusps and a relaAmerican Journal of Suvgery
Tricuspid some\vhat reduced orifice. The usually a little thickened but the In&n substance of the cusps is thin and pliable. The chordae tcndincac are unthickened and 1111fu5eti although they may appear more crcl\vcled than norlnal. The commissural areas ;Lrc’ obliterated but there is no separable line (11‘fusion, \uch as i\ evident in cases of mitral \tcnosis. It is as if there has been a concentric shortening of the free edge of the valve, which is maximal in the commissural areas, together \vith some shortenin g of the main cusps. This ‘;cirves to lessen the difference in depth between the cusps and the commissural tissue and to shorten the length IJt‘ the tissue so that in the most extreme form the valve is converted into a thill and still pliable washer, with no distinct cusps and with a central orifice that is both inoderately stenotic and freely incompetent. The sites usually used for the annuloplasty stitches are not in evidence and indeed shortvning the ring at several points merely crimps and increases the stenosis the “diaphragm” without producing a valve with cusps that can meet each other properly. Cutting into \vhat is left of the commissural areas helps \.cry little since more than a very shallow cut gets out into cusp tissue which is unsupported by chordae tenclineae and is therefore incompetent [5]. If the degree of stenosis is tolerable, pericardial or homograft extension of one half of the cusp tissue can work very 1~41 171. By contrast to the normal cusp tissue oithe “functionally” incompete;t valve, that cd the organically diseased valve, although Ijliable, is thick enough to hold stitches. Nevertheless, in the presetIce of organic incompetence it is often impossible. despite the presence of lnuch pliable cusp tissue, to perform an adecjuate plastic repair. ti\-cI!,
fiseci.
l’rc‘c‘ edges
are
KESLXTS
Six patients have been followed up for from six to eighteen months after tricuspid annuloplasty for hemodynamically severe tricuspid insufficiency. (Annuloplasty stitches have been used in a number of other patients not included in this series, who had moderate or minor degrees of tricuspid insufficiency.) .I11 the patients had surgery on the mitral valve and two had aortic valve replacements as well. All were in class IV functionally. The
Annuloplast
y
tnean
pulmonary arterial pressure for thehe patients ranged between 35 and li.? mm. Hg. Five had pure incompetence tluc to dilated valvt ririgs and one had sonic organic changes as well. In this last patient a cautious in&ioIl in one commissural area ~~35 used in additiott to the almuloplasty stitches. I’reoperativcly, all the patients had large “I”’ L\XVCS in the jugular pulse and markedly pulsating livers besides the usual evidence of congestive heart failure. Postoperatively, although mean right atria1 pressures were above normal for a ieli days, by the time the patients left the hospital the pressure5 were no longer raised. The “I?” wave in the jugular pulse had disappearctl ant! the hepatic pulsation could no Irqer be detected. No murmurs of tricuspid insuf’licienc\ could be heard. The findings, ha\-c persist&l throughout the follow-up periotl. (he pat&l t requires diuretics to prevent recurrence of ascitc\. Significant tricuspid insuf?iciency accompanying lesions of the mitral and aortic valves produces serious effects if they are not repaired at the same time as the left sided lesions. The technic of tricuspid annuloplasty is described, a procedure which if properly performed is most useful and successful. REFERENCES 1. KAY, J. H., TSUJI, H. K., MASELLI, G. and CA.ZIPAGNA, M. D. Surgical treattncnt of tricuspid insufficiency. .lnn. Skip., 162: 53, l!l65. 2. FRATER. R. W. M.. BARNARD. C. S.. SCHRIRH. \-. Open heart surgery for rhrutnatic tliscaw of t,llr mitral valve. .S. .Ifricnn 211. .I.,38: TX, 1964. 3. LILLEHEt, c. W., GANKOS. I’. c;.. I,E\.Y, M. 1 I'ARCO. R. L.. and WANG, V. \‘alve replacement for tricuspid strnosis or insufficiency asswiatcd witlt mitral valve diseasr. Ci~z6/ation, 33: 3-k. I#% 4. STARR, .I.. HERR, R. H.. WOOD, -1. .\., EI)\YARI)~, M. I... and GRISWOLD. H. E. Tricuspid rcplaccmcnt: clinical rsprrience with the lxx11 V:I!VC, prosthesis. Circulation, 11: 202. 1065. 5. FRATER. R. W. M. Anatomical rulrs for tltc plastic repair of it diseased mitral valve. ?‘hows. 10: -I%%, In&+.
6.
7.
WOOLER. G. H., x1X0x, I’. G. F.. C;RrblSHA\\., \ :\ , and WATSON, I>. h. Experiwces with tltc wpxir of the mitral valve in mitral ittc~n~~petcw.-c. ?‘liow.r. 17: 49. 1%‘~. , I FRATER, R. W. M., BEGHUtS. J and BRO:\Z, 3. I,.. JR. The experimental and clinical USC 01 autoaenous pericardium for the replaccm~~nt ;1t1,1 extension of mitral and tricuspid cusps :t!td clt~~rdae. .I. Cniditmns. Surg., 6: 911, l!x.i.