Tricuspid Valve Repair—Indications and Techniques: Suture Annuloplasty and Band Annuloplasty

Tricuspid Valve Repair—Indications and Techniques: Suture Annuloplasty and Band Annuloplasty

Tricuspid Valve Repair—Indications and Techniques: Suture Annuloplasty and Band Annuloplasty Antonio Maria Calafiore, MD,* and Michele Di Mauro, MD*,†...

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Tricuspid Valve Repair—Indications and Techniques: Suture Annuloplasty and Band Annuloplasty Antonio Maria Calafiore, MD,* and Michele Di Mauro, MD*,†


ecently there has been new interest in the tricuspid valve, as different research identified late tricuspid regurgitation, often a consequence of uncorrected lesion during surgery, as a determinant of poor clinical outcome and even of higher late mortality.1,2 However, it is still not clear when, at the first operation, functional tricuspid regurgitation has to be corrected. In most of the surgical articles, the decision to perform tricuspid valve (TV) repair during mitral valve (MV) surgery was left to the surgeon’s discretion or even was not specified.2-5 The 2008 American Heart Association/American College of Cardiology guidelines6 suggested to perform TV annuloplasty in patients with severe tricuspid regurgitation (TR) requiring MV surgery for MV disease (class IB); TV annuloplasty for TR less than severe should be indicated in patients undergoing MV surgery having pulmonary hypertension or tricuspid annular dilation (class IIB). The European Society of Cardiology (ESC) guidelines7 suggested to perform TV annuloplasty in severe TR undergoing left-sided valve surgery (class IC) and in moderate TR with dilated annulus (maximum systolic tricuspid annulus, TA, ⬎40 mm, 4-chamber view) in patients undergoing left-sided valve surgery (class IIA, level C). A different surgical vision was presented by Dreyfus and coworkers,8 who suggested performing tricuspid annuloplasty regardless of the grade of trisupid regurgitation, when the tricuspid annular diameter was greater than twice the normal size (⬎70 mm). The measurement of TA diameter (distance between the anteroseptal commissure and the anteroposterior commissure) was performed in the operative field, when the right atrium was vertically opened, using a simple ruler. Our group9 based the decision to perform TV annuloplasty on the preoperative echocardiographic TA systolic dimensions, as TR happens in systole. We found in a cohort of 20 volunteers a median systolic TA value of 24 mm with a maximum of 28 mm; thus, we decided to perform TV annuloplasty in all cases of moderate-to-more TR and in the case of mild functional TR when systolic TA was higher than 24 mm. The results of our study demonstrated that patients

*Department of Adult Cardiac Surgery, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia. †Institute of Cardiology, University of L’Aquila, L’Aquila, Italy. Address reprint requests to: Antonio Maria Calafiore, MD, Department of Adult Cardiac Surgery, Prince Sultan Cardiac Center, Riyadh, Kingdom of Saudi Arabia. E-mail: [email protected]


1522-2942/$-see front matter © 2011 Elsevier Inc. All rights reserved. doi:10.1053/j.optechstcvs.2011.06.002

with systolic TA ⱕ24 mm, who did not undergo TV annuloplasty besides MV surgery, did not show any increase of TR grade, at least in the mid term, whereas most of the untreated patients who showed moderate TR grade or more in the follow-up had preoperative systolic TA within the range of 25 to 28 mm. The rate of untreated patients having preoperative mild TR and systolic TA ⬎24 mm, whose TR was impaired to moderate or more at follow-up, was 10%. However, the tricuspid valve is not only annulus, but also leaflets, chords, and papillary muscles, the position of which depends on the right ventricle size and function. Today, surgical strategies are directed mainly to the annulus or to the annulus and the leaflets, as in the Kay technique.10 Other techniques, addressed to the leaflets, can be interesting in selected cases, as the edge-to-edge technique (associated with a rigid incomplete ring or a flexible band)11 or leaflet augmentation.12 These techniques, not yet standardized, are used mainly when there is excess chordal tethering, with increased coaptation depth of the tricuspid valve (the distance between the annular plane and the point where the leaflets coapt). This latter concept, not yet well investigated, was introduced by Fukuda and coworkers,4 who considered a cut point for increased early failure rate of the annuloplasty, 6.8 mm, for late failure 5 mm, lower than the 10 mm identified for the mitral valve. Interestingly, these authors found a correlation between early postoperative ejection fraction ⬍36.6% and late failure of TV repair, reinforcing the concept that annuloplasty alone will not prevent TR return as a consequence of LV failure, which will cause right ventricle (RV) continuous remodeling. The strict relationship found in the left system (MR return for left ventricular remodeling) was found in the RV, where, however, causes of remodeling are multiple, intrinsic, or extrinsic to the RV itself. Furthermore, the association between annular size and TR is not completely clear. In an interesting study, Sadeghi and coworkers13 reported 27 patients with pulmonary thromboembolism who had severe pulmonary hypertension and severe TR. They underwent surgery without TV annuloplasty. In 19 patients (70%), the pulmonary pressure dropped by a mean of 49 mm Hg and TR was reduced to mild. In the remaining 30% of patients, TR remained severe; pulmonary pressure reduced to 32 mm Hg, less than in the other group. Interestingly, in both groups the annular size remained nearly unchanged (4-mm reduction between pre- and postoperative echocardiograms) and similar (41 mm in the first group and 42 mm in the second

Tricuspid valve repair techniques


Figure 1 Anatomic view of the tricuspid valve. The annulus is enlarged. The anterior and septal leaflets are represented more than the posterior. The suture line, both in De Vega suture annuloplasty and in band annuloplasty, starts from A (the anteroseptal commissure, AS commissure) and ends in B (in front of the origin of the coronary sinus, CS). The portion of the septal leaflet included from CS and the posteroseptal commissure (PS commissure) is part of the free wall of the right ventricle. P1, P2, and P3 represent the papillary muscles, which are not as constant in number and position as in the mitral valve apparatus. AP ⫽ anteroposterior.

group in the postoperative assessment). We can deduce that, even if the annulus remains dilated, this does not prevent TR reduction, but the mechanisms related to RV reverse remodeling, following pulmonary artery pressure (PAP) reduction of different degrees, are more important than the pure annular size. Oppositely, the impact of pulmonary hypertension on severity of TR, a concept that can be easily inferred by the previous study, is not always clear. In a recent echocardiographic evaluation of 2139 subjects with pulmonary hypertension, Mutlak and coworkers14 found that TR was only mild in almost 65% of subjects with PAPs 51 to 69 mm Hg and 46% of those with PAPs ⬎70 mm Hg. Other factors, and among them RV remodeling was one of the most important, were at the basis of the onset of more severe grade of TR. Unfortunately, as the mechanism of functional TR does not dwell only in the annulus, the surgical techniques usually applied, mainly directed to annular reduction, have fluctuating results. The RV geometry seems to be predominant in the outcome of early and late results after TV repair, but its modifications are often unpredictable, as its positive remodeling depends on multiple factors not always related to the surgical technique applied. As no technique in use today addresses the RV geometry, we are aware that the results of TV repair are not constant and are by far less predictable of the results of MV repair.

Tricuspid valve annuloplasty can be performed using a suture, a strip of autologus pericardium, by means of an incomplete ring implantation, rigid or flexible (band), 3D shaped or planar. The procedure described by De Vega in 197215 consists of a double-layer suture annuloplasty starting twice from the anteroseptal commissure and ending twice at the level of the posteroseptal commissure. The final orifice was gauged by means of 2 fingers. The surgical technique for incomplete ring or band is roughly the same. The interrupted sutures start at the level of the anteroseptal commissure and end at the level of the posteroseptal commissure or at different levels of the septal annulus. The conundrum of annular reduction for functional TR is how much the annulus has to be tightened. We prefer to remodel the annulus over a no. 25 sizer, which provides a circumference of 78.5 mm,16 but this value is largely at the surgeon’s discretion. When a band annuloplasty is used, the same concept is followed.17 The constant length of the band is 50 mm; as the sutures stop at the level of the coronary sinus, what remains is the short distance between the points A and B (Fig. 1), roughly 30 mm. We herein describe the 2 surgical techniques of tricuspid annuloplasty, which we constantly use in our experience.

A.M. Calafiore and M. Di Mauro


Operative Technique

Figure 2 De Vega suture annuloplasty. The pledgeted suture (2-0 Ti-cron) starts from the anteroseptal commissure and ends in front of the origin of the coronary sinus.

Tricuspid valve repair techniques

Figure 3 After the first suture line is completed, a second line is started close to the first one, to be ended again at the level of the coronary sinus, in such a way that the 2 suture lines are superficial or deep alternatively. The differences with the original technique described by De Vega15 are mainly 2. The first is the suture, as we do not use a monofilament suture, which can cut the annulus, causing the “guitar chord sign,” but a 2-0 or 3-0 polyester suture. The second is where the suture ends. We go over the posteroseptal commissure to the septal annulus in front of the coronary sinus, including the entire free wall of the right ventricle, avoiding further annular dilation in this part of the annulus.


A.M. Calafiore and M. Di Mauro


Figure 4 Both needles of the same suture are passed into a pledget.

Tricuspid valve repair techniques

Figure 5 A cylindrical sizer no. 25 (or a bigger sizer, according to the surgeon’s preference) is positioned inside the tricuspid annulus and the suture is tied to be adapted to the sizer itself.



A.M. Calafiore and M. Di Mauro

Figure 6 The final result shows a tricuspid annulus reduced in the part of its circumference related to the free wall of the right ventricle (from point A to B, long distance, Fig. 1).

Tricuspid valve repair techniques

Figure 7 Flexible band annuloplasty. The interrupted sutures (2-0 Ti-cron) start at the same point as in Fig. 2.


A.M. Calafiore and M. Di Mauro


Figure 8 The sutures end in front of the origin of the coronary sinus.

Tricuspid valve repair techniques


Figure 9 A 50-mm band (SMB50; Sorin, Saluggia, Italy) is positioned, to reduce the tricuspid orifice to the circumference of a no. 25 sizer, as in Fig. 3. The distance not covered by sutures is approximately 30 mm (the circumference of a no. 25 sizer is 78.5 mm).

Conclusions How to repair functional tricuspid regurgitation is still a work in progress. Techniques at our disposal are mainly addressed to the annulus, and De Vega suture annuloplasty and band annuloplasty are the most used. The decision to perform a De Vega procedure or a ring– band implantation is more often related to the single surgeon’s choice. We reported an echocardiography-based decisionmaking to establish whether De Vega is indicated or not. In the case of a moderate-or-more functional tricuspid regurgitation (FTR) grade with systolic TA up to 28 mm, De Vega was indicated, whereas the band was implanted for systolic TA dimensions higher than 28 mm. In the case of mild FTR, De Vega was performed with systolic TA 25 to 28 mm and the band was implanted when systolic TA was higher than 28 mm.9

Nowadays, there is more sensibility toward the correction of TR, at least moderate in grade, even if, sometimes, any grade of TR is corrected. Our group demonstrated that, in patients with functional MR, untreated less-than-moderate functional TR provided better 5-year survival and survival in New York Heart Association class I-II than untreated moderate-or-more functional TR.1 Contrarily, comparing patients with functional MR and moderate-or-more functional TR, treatment of FTR with De Vega suture annuloplasty limited the incidence, at follow-up, of residual FTR 3/4 or 4/4 and provided better survival and survival in New York Heart Association class I-II.2 Results from TV annuloplasty are still not perfect, as the ventricular component is, today, not addressed by the techniques commonly used.18 As persistent RV dilation means increased tethering on the TV leaflets, TV annuloplasty failure can be related to lack of RV volume regression or pro-

A.M. Calafiore and M. Di Mauro

96 gressive RV failure due to TV-related causes or lack of regression of pulmonary hypertension. Nevertheless, in most cases suture or band annuloplasty is enough to assure good mid-term clinical and anatomical results.

References 1. Di Mauro M, Bivona A, Iacò AL, et al: Mitral valve surgery for functional mitral regurgitation: prognostic role of tricuspid regurgitation. Eur J Cardiothorac Surg 35:635-640, 2009 2. Calafiore AM, Gallina S, Iacò AL, et al: Mitral valve surgery for functional mitral regurgitation: Should moderate-or-more tricuspid regurgitation be treated? A propensity score analysis. Ann Thorac Surg 87: 698-703, 2009 3. McCarthy PM, Bhudia SK, Rajeswaran J, et al: Tricuspid valve repair: Durability and risk factors for failure. J Thorac Cardiovasc Surg 127: 674-685, 2004 4. Fukuda S, Gillinov AM, McCarthy PM, et al: Determinants of recurrent or residual functional tricuspid regurgitation after tricuspid annuloplasty. Circulation 114:I582-I587, 2006 5. Ghanta RK, Chen R, Narayanasamy N, et al: Suture bicuspidization of the tricuspid valve versus ring annuloplasty for repair of functional tricuspid regurgitation: Midterm results of 237 consecutive patients. J Thorac Cardiovasc Surg 133:117-126, 2007 6. Nishimura RA, Carabello BA, Faxon DP, et al: 2008 focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease. JACC 52:e1-e142, 2008 7. Vahanian A, Baumgartner H, Bax J, et al: Guidelines on the management of valvular heart disease. The Task Force on the Management of



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Valvular Heart Disease of the European Society of Cardiology. Eur Heart J 28:230-268, 2007 Dreyfus GD, Corbi PJ, Chan KM, et al: Secondary tricuspid regurgitation or dilatation: Which should be the criteria for surgical repair? Ann Thorac Surg 79:127-132, 2005 Calafiore AM, Iacò AL, Bivona A, et al: Echocardiographically based treatment of functional tricuspid regurgitation. J Thorac Cardiovasc Surg 2011 (in press) Kay JH, Maselli-Campagna G, Tsuji HK. Surgical treatment of tricuspid insufficiency. Ann Surg 162:53-58, 1965 De Bonis M, Lapenna E, La Canna G, et al: A novel technique for correction of severe tricuspid valve regurgitation due to complex lesions. Eur J CardioThoracic Surg 25:760-765, 2004 Dreyfus GD, Raja SG, Chan KMJ: Tricuspid leaflet augmentation to address severe tethering in functional tricuspid regurgitation. Eur J Cardiothorac Surg 34:908-910, 2008 Sadeghi HM, Kimura BJ, Raisinghani A, et al: Does lowering pulmonary arterial pressure eliminate severe functional tricuspid regurgitation? Insights from pulmonary thromboendarterectomy. JACC 44:126-132, 2004 Mutlak D, Aronson D, Lessik J, et al: Functional tricuspid regurgitation in patients with pulmonary hypertension: Is pulmonary artery pressure the only determinant of regurgitation severity? Chest 135:115-121, 2009 De Vega NG: La anuloplastia selective regulable y permanente. Rev Esp Cardiol 25:555-556, 1972 Frater R: Tricuspid insufficiency. J Thorac Cardiovasc Surg 125:9-11, 2003 Calafiore AM, Iacò AL, Contini M, et al: A single size band, 50 mm long, for tricuspid annuloplasty. Eur J Cardiothorsc Surg 34:677-679, 2008 Navia JL, Novicki ER, Blackstone E, et al: Surgical management of secondary tricuspid valve regurgitation: annulus, commissure, or leaflet procedure? J Thorac Cardiovasc Surg 139:1473-1482, 2010