Asian Cardiovasc Thorac Ann 2000;8:292-293
© 2000 Asia Publishing EXchange Pte Ltd
New Technique of Tricuspid Annuloplasty
Mert Kestelli, MD,
Levent Yilik, MD,
brahim Özsöyler, MD,
Tayfun Gökdo
an, MD,
Banu Akda, MD,
Cengiz Özbek, MD
Department of Cardiovascular Surgery
zmir Atatürk Education and Research Hospital
zmir, Turkey
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For reprint information contact: brahim Özsöyler, MD Tel: 90 232 323 2270 Fax: 90 232 243 4848 email: ibrahimozsoyler{at}yahoo.com Ahmet Hasim Sokak Cilek Apt. No. 8/A D:2, Narlidere, zmir, Turkey.
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Abstract
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This technique using only 3/0 polypropylene suture, provides reconstruction appropriate to the anatomy and physiopathology of functional tricuspid insufficiency. Problems such as the gliding effect, pannus formation, and infection, should be minimal. The technique was successfully applied in 3 patients.
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Introduction
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Functional tricuspid regurgitation (FTR) is defined as annular dilatation without intrinsic involvement in the tricuspid valve, whether or not there is right ventricular dilatation depends on an increase in the afterload or pre-load of the right ventricle. The ability of the annulus to reduce both its circumference and its area is significantly diminished in FTR. Although many surgical techniques have been devised to eliminate this pathology, most have drawbacks such as insufficient elimination or recurrence of tricuspid regurgitation, pannus formation and sus-ceptibility to infection, and high cost. A new annuloplasty technique was developed to eliminate these drawbacks.
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Technique
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Following induction of general anesthesia and aortobicaval cannulation, cardiopulmonary bypass is instituted under moderate hypothermia (28°C) with blood cardioplegia, the heart is arrested with anterograde cold potassium cardioplegia. After repair of the primary pathology, a Carpentier-Edwards (Baxter-Edwards AG, Horw, Switzerland) tricuspid valve sizer no. 32 is used in female patients and a no. 34 sizer in males to assess the annular reduction required. A U-shaped 3/0 polypropylene suture is placed at the posteroseptal commissural annulus (Figure 1
). This area is plicated and tied with 4 knots (Figure 1–a). With both needles of the suture parallel (the two ends are free), suturing is continued in the posterior annulus at 3-mm intervals. After each bite, taking the tricuspid valve sizer as a reference, the two ends of the suture are tied with 4 knots, with or without plication. When the posteroanterior commissure is reached, this area is drawn together in 3-mm steps and tied securely (Figure 1–b). Similarly, the anterior leaflet annulus is sutured at 3-mm intervals with plication if necessary, and secured with 4 knots at each stage until the anteroseptal commissure is reached. The anteroseptal commissure annulus is plicated in 3-mm steps and tied with 8 knots (Figure 1–c). Intraoperative coaptation tests are performed by filling the right ventricle with cardioplegic solution.
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Figure 1. Tricuspid annuloplasty technique. U-shaped sutures are placed in the annulus starting at the posteroseptal commissure. The annulus is plicated and tied with 4 knots (a). Suturing is continued in steps of 3 mm using a sizer as a guide to plication. At the posterior anterior commissure, the dilated annulus is tightened (b). Similarly, on the anterior leaflet annulus, plication is continued up to the anteroseptal commissure. The anteroseptal commissure annulus is plicated and tied with 8 knots (c).
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Discussion
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This technique was applied in 3 patients with serious FTR. A 38-year-old woman had grade-4 FTR and mitral stenosis, a 42-year-old man had grade-3 FTR and mitral stenosis, and a 40-year-old woman had grade-4 FTR and a septum secundum type of atrial septal defect. Mitral valve replacement in the first 2 patients and atrial septal defect repair in the 3rd patient were undertaken before tricuspid annuloplasty. There were no postoperative problems. After 6 months, echocardiograms showed only minimal tricuspid insufficiency and all 3 patients were in New York Heart Association functional class I.
While correcting the physiopathology, tricuspid annulo-plasty should not conflict with the physiology of leaflet coaptation and it must be durable. In de Vega annuloplasty, a "guitar string" phenomenon may result from a gliding effect.1,2 Although the dilated nonseptal part of the annulus is drawn together, which part and how much are generally uncertain. Moreover, a semicircular deformation with leaflet curving results in structural leaflet deformity in the long term. In the modified de Vega annuloplasty devised by Arai and colleagues3 to eliminate the "guitar string" phenomenon, the process starts on the annulus at the middle of the septal leaflet instead of the anteroseptal commissure, and the suture is brought up to the postero-septal commissure. However, this technique does not always eliminate the gliding effect and it may increase the chances of atrioventricular block. The use of pledgets to prevent the "guitar string" phenomenon may lead to pannus formation that prevents annular contraction and increases the risk of infection. Because of its homogeneous segmentary annular shortening, the Carpentier flexible ring was found to be superior to de Vega annuloplasty.4 However, the flexible ring can decrease its area only by changing its shape and it cannot reduce its circumference; this can cause suture disruption. Although the ring is flexible, it conflicts with leaflet coaptation physiology by producing external or internal bulging due to local rigid effects. The atrioventricular valve annulus normally decreases its systolic area (necessary for coaptation) by reducing its circumference, which is not possible with the flexible ring; additional drawbacks are its cost and susceptibility to pannus formation and infection. Furthermore, there is an increased risk of stenosis with overcorrection in adjustable de Vega annuloplasty.5 In the partial plication method, pannus formation and nonplicated dilated segments are potential problems of this method. In the bicuspidization process, a leaflet is removed and the underlying ventricle tissue is plicated, thereby distorting right ventricular geometry. With only 50% of the dilatation eliminated, a 41% recurrence of tricuspid regurgitation was reported.6
The tricuspid valve is supported by only one fibrous trigone, whereas the mitral annulus has two. Since the contact length of the tricuspid annulus with the myo-cardium is longer, the ratio of systolic annular reduction is higher than that of the mitral annulus. This should be considered when performing tricuspid valve recon-struction. Since our technique includes the plication of small suture intervals or ligation without plication, it does not draw the ventricle together. Because the suture is tied at each step, the gliding effect is minimized and systolic annular reduction is not inhibited. Pannus formation and the risk of infection are reduced. It is also cost-effective. The physiopathology is totally corrected because the drawing together is carried out in accordance with a sizer. Unlike the flexible ring, circumferential shortening is not hindered. However, long-term results are necessary to assess durability.
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References
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Abe T, Tukamoto M, Yanagiya M, Morikawa M, Watanabe N, Komatsu S. De Vega's annuloplasty for acquired tricuspid disease: early and late results in 110 patients. Ann Thorac Surg 1989;48:670–6.[Abstract]
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Revuelta JM, Garcia-Rinaldi R. Segmental tricuspid annuloplasty: a new technique [letter]. J Thorac Cardiovasc Surg 1989;97:799–801.
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Arai T, Hashimoto K, Horikoshi S, Matsui M, Suzuki S. Modification of de Vega tricuspid annuloplasty [letter]. J Thorac Cardiovasc Surg 1991;102:320–1.[Medline]
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Rivera R, Duran E, Ajuria M. Carpentier's flexible ring versus de Vega's annuloplasty. J Thorac Cardiovasc Surg 1985;89:196–203.[Abstract]
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De Simone R, Lange R, Tanzeem A, Gams E, Hagl S. Adjustable tricuspid valve annuloplasty assisted by intraoperative transesophageal color Doppler echo-cardiography. Am J Cardiol 1993;71:926–31.[Medline]
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Pluth JR, Ellis FH Jr. Tricuspid insufficiency in patients undergoing mitral valve replacement. J Thorac Cardiovasc Surg 1969;58:484–91.
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Abstract
Introduction
