Fig. 22.1
Orientation and degree of the annular dilatation as assessed intraoperatively (Dreyfus et al. [3]. Permission granted by Elsevier)
Subsequently, the ESC/EACTS guidelines, published in 2012, recommended that “surgery of the tricuspid valve should be considered in patients with moderate primary TR undergoing left-sided valve surgery (IIa)” and that “surgery should be considered in patients with mild or moderate secondary TR with dilated annuli (≥40 mm or >21 mm/m2 undergoing left-sided valve surgery (IIa)” [4]. On the other hand, the 2014 AHA/ACC guidelines suggest, as class IIa recommendation, that “tricuspid valve repair can be beneficial for patients with mild, moderate, or greater functional TR (stage B) at the time of left-sided valve surgery with either (1) tricuspid annular dilation or (2) prior evidence of right HF” [5].
Surgical Operative Techniques
In my opinion, only exceptionally will the TV need to be replaced as a first procedure, because the valve tolerates well a less-than-perfect repair (even in many cases of organic rheumatic disease, infective endocarditis, etc.). Hence, annuloplasty, when feasible, is the surgery of choice.
The first tricuspid annuloplasty was described in 1965 by Kay, as a modification of the mitral procedure he had described 2 years earlier. This pioneer used “three or four figure-of-eight sutures of 1-0 silk” to obliterate most, if not all, of the annulus of the anterior-inferior leaflet (currently denominated posterior leaflet) to “decrease the size of the annulus from an initial four or five finger breadths to two and one half finger breadths” [6], thus resulting in bicuspidization of the tricuspid valve (Fig. 22.2). The results then described were very encouraging and the procedure was quickly adopted by the surgical community.
Fig. 22.2
The Kay procedure was the first tricuspid annuloplasty described. It consisted of 3 or 4 simple figure-of-eight sutures obliterating the posterior portion of the annulus, thus resulting in bicuspidization of the valve
In 1973, Alain Deloche and colleagues, from the Paris group, reported that 5/6 of the tricuspid annular dilatation occurs in the mural segment, free wall of the right ventricle, which corresponds to the anterior and posterior leaflets (Fig. 22.3) [7]. Dr. Norberto de Vega, from Malaga, Spain, (Fig. 22.4) probably had the same intuition as, in 1972, he described that “the tricuspid regurgitation is usually caused by a selective expansion of the part of the tricuspid ring closely related to the free wall of the right ventricle (RV), area in which the anterior and posterior leaflets of the tricuspid apparatus are inserted” [8]. Hence, he devised the operation that carries his name and was then adopted by the majority of the surgeons. Classified as a selective, adjustable and permanent annuloplasty, it consists of a double continuous suture plication of the annulus, commenced anchored to the right fibrous trigone, at the level of the antero-septal commissure, and run along the annulus, ending at the level of the postero-septal commissure, both ends supported with Teflon pledgets (Fig. 22.5).
Fig. 22.3
In 5/6 of the cases, tricuspid annular dilatation occurs in the mural segment, free wall of the right ventricle (green line), which corresponds to the anterior and posterior leaflets
Fig. 22.4
Dr. Norberto De Vega
Fig. 22.5
De Vega suture annuloplasty. It consists of a double continuous suture extending from the antero-septal to the postero-septal commissures (Antunes and Barlow [1]). (a) A single row of suture (pledgeted at one end) is first placed along the annulus from the postero-septal commissure to the antero-septal commissure (where it is then passed through a pledget). (b) The same suture is then placed along the annulus again in the opposite direction forming a second row of sutures, and passing through the initial pledget, and tied after adjusting to the required length
The procedure is simple and reproducible and only implies one important technical consideration, which consists of avoiding the right coronary artery which runs close to the anterior portion of the annulus. This requires somewhat superficial placement of the sutures and the procedure was often complicated by the ‘guitar-string syndrome’ which resulted of the suture tearing from the tissues.
To avoid this complication, in 1983 we described a simple modification of the De Vega technique which consists of the interposition of a small Teflon pledget in each bite in the annulus in both rows of the suture (Fig. 22.6) [9]. Since then, after more than one thousand procedures, we have not again seen a single case of that complication. A similar principle was used in 1989 by Revuelta et al. who used interrupted sutures supported by the Teflon pledgets along the annulus and termed it segmental tricuspid annuloplasty [10]. Another modification was described in 2007 by Sarraj and Duarte, who used a type of adjustable De Vega which consists of dividing it into two parts and using tourniquets to sequentially adjust the length of each part, hence the tightening of the orifice until competence is achieved (Fig. 22.7) [11].
Fig. 22.6
Modified De Vega annuloplasty described by Antunes and Girdwood. It consists of the interposition of Teflon pledgets for each bite of the two-row suture (Antunes and Barlow [1]). (a) A single row of suture (pledgeted at one end) is first placed along the annulus from the postero-septal commissure to the antero-septal commissure; each bite of the suture through the annulus passes through a pledget. (b) The same suture is then placed along the annulus again in the opposite direction forming a second row of sutures; each bite through the annulus is again passed through a pledget. (c) The final result after tying the suture having determined the appropriate size
Fig. 22.7
Adjustable annuloplasty AS described by Saraj et al. (Ann Thorac Surg. 2007; 83: 698–9). This modification of the De Vega annuloplasty consists of two double-row sutures which can be tightened sequentially by tourniquets, thus selectively adjusting the size of the orifice (With permission from Elsevier)
Many other modifications were suggested but all were based on the concept idealised by De Vega and should all be named as modifications of the initial procedure. As initially described by De Vega, we use a monofilament propylene suture (size 3-0), but others use a 2-0 or 3-0 polyester suture [12].
Parallel to this evolution, Carpentier developed the ring concept in 1968, initially for treatment of the mitral valve regurgitation, followed by use in the tricuspid valve [13]. It consisted of a pre-shaped rigid flat ring which is almost complete but for the portion of the annulus where the bundle penetrates the ventricular septum. A possible downside of this concept is the fact that the ring fixes the annulus, thus preventing its natural dynamics during the cardiac cycle. Based on this, Duran and co-workers described the flexible ring in 1976 [14], which permits the dynamic alteration of the shape, but still prevents dilatation of the tricuspid orifice during diastole. Besides, the flexible ring becomes progressively stiff with time as a consequence of endothelial ingrowth, eventually even calcification. Many other types of rings and bands have been described and used clinically.
Results of Treatment
The techniques described are reproducible and easy to master, however requiring adherence to some important details, and can be performed rapidly, usually taking no longer than 10–15 additional minutes of operating time, hence with minor influence on morbidity or mortality. If necessary, the annuloplasty can be performed with the heart beating or fibrillating, after release of the aortic crossclamp. Apart from the suture material (and of pledgets), there is an absence of prosthetic material, which is an important consideration. And for those concerned about flexibility, it is fully preserved, although fibrosis around the sutures (and the pledgets) tends to transform it into a kind of band. Naturally, much cheaper than any commercially available devices, and this was a main consideration when Kay and De Vega devised their techniques. It may still be important today.
A few years ago, the group of Larry Cohn, from Boston, analysed 237 patients who underwent tricuspid annuloplasty for secondary tricuspid regurgitation as part of their cardiac surgical procedure, from 1999 to 2003. Bicuspidization was performed in 157 patients and ring annuloplasty in 80 patients. They found that both bicuspidization and ring annuloplasty were effective at eliminating tricuspid regurgitation at 3 years postoperatively. In fact, at that interval, both survival (75.3 % in the bicuspidization and 61.2 % in the ring annuloplasty group) and freedom from recurrence of moderate TR (75 % vs 69 %) tended to be better in bicuspidised patients than in those who received a ring. In the majority of the 44 patients (18.6 %) in whom moderate or greater recurrent TR developed, it happened within the first 6 months in both groups (Fig. 22.8). Hence, they concluded that “bicuspidization annuloplasty is a simple, inexpensive option for addressing functional tricuspid regurgitation” [15].
