The aorta, SVC and IVC should be cannulated and tapes passed around the SVC and IVC. These should be snugged prior to opening the right atrium. The tricuspid valve is approached, either through a vertical or horizontal atriotomy. A vertical atriotomy is performed from the atrial appendage towards the inter-atrial septum while a horizontal atriotomy is performed from the atrial appendage towards the IVC cannula site (Fig. 6.1).

A systematic analysis of the tricuspid valve is performed. The tricuspid valve is first inspected (Fig. 6.2). Note is made of any excessive leaflet tissue, leaflet perforations, ruptured chordae or ruptured papillary muscles. The lesion is then determined using a pair of nerve hooks. Each part of the tricuspid valve leaflet is lifted up, in turn, to determine the presence of prolapse or tethering. The tricuspid annular diameter is then measured. This is generally taken as the distance between the anteroseptal commissure and the anteroposterior commissure (i.e. the direction of maximal dilatation). It is considered dilated if it is greater than 70 mm when measured intraoperatively. This corresponds to a diameter of 40 mm when measured preoperatively by transthoracic echocardiography in a four chamber view (which measures the distance from the middle of the septal annulus to the middle of the anterior annulus). Most cases of functional tricuspid regurgitation are due to tricuspid annular dilatation and tricuspid annuloplasty is usually sufficient to address this.

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