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Ann Thorac Surg 1997;64:267-268
© 1997 The Society of Thoracic Surgeons

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How To Do It

Tricuspid Valve Repair With the Cosgrove-Edwards Annuloplasty System

Department of Thoracic and Cardiovascular Surgery, The Cleveland Clinic Foundation, Cleveland, Ohio

Accepted for publication January 16, 1997.

	Abstract

Top Footnotes Abstract Introduction Technique Comment References

 
The technique of tricuspid valve repair with the Cosgrove-Edwards Annuloplasty System is described. This system provides a measured plication of the tricuspid valve annulus with a technique that is easily reproducible and permits physiologic motion of the tricuspid annulus.

	Introduction

Top Footnotes Abstract Introduction Technique Comment References

 
Tricuspid regurgitation may occur in isolation or in combination with other valvular or congenital heart disease. Ten percent to 50% of patients with severe mitral stenosis or mitral regurgitation [1, 2] have tricuspid regurgitation, which is generally functional in nature. Valve repair is preferable to valve replacement because of the imperfect performance of all prostheses. Recently, our understanding of the physiology of the tricuspid annuloplasty has increased. Computer-generated reconstructions of the tricuspid annulus based on multiple echocardiographic images demonstrate the tricuspid annulus is a saddle-shaped structure that has sphincter action, being smaller in systole than in diastole [3]. Anatomic studies demonstrated that five-sixths of annular dilatation takes place at the base of the anterior and posterior leaflets [4]. This understanding of the normal physiology and pathoanatomy of the tricuspid valve led us to pursue the development of an annuloplasty system that is universally flexible and produces a measured plication of the annulus at the base of the anterior and posterior leaflets. Repair of the tricuspid valve using the flexible Cosgrove-Edwards Annuloplasty System (Baxter Healthcare, Irvine, CA) is described.

	Technique

Top Footnotes Abstract Introduction Technique Comment References

 
After median sternotomy and pericardiotomy, the patient is systemically heparinized. The superior vena cava and inferior vena cava are individually cannulated and the patient is placed on cardiopulmonary bypass. The ascending aorta is cross-clamped, and cardioplegia is administered in antegrade and retrograde fashion. Left-sided heart lesions, if present, are corrected first. A right atriotomy is then performed and the tricuspid valve examined. After correction of any abnormalities in the leaflets, a tricuspid annuloplasty is performed using the Cosgrove-Edwards Annuloplasty System [5]. Using the Carpentier-Edwards sizer, the appropriate size is selected based on the length of the attachment of its septal leaflet. This should correspond to the distance between the notches on the sizer. Interrupted mattress sutures are placed in the tricuspid annulus beginning at the posteroseptal commissure and extending around the annulus to the anteroseptal commissure. The sutures are placed through the polyester velour band (Fig 1) and the annuloplasty system is slid into position. The handle is removed from the frame (Fig 2) and the sutures are sequentially tied, reducing the size of the annulus. The handle is still connected to the frame by a lanyard, which facilitates removal of the frame. The band is released from its frame by cutting three sutures (Fig 3). A measured plication of the portion of the annulus corresponding to the anterior and posterior leaflets is achieved and the area near the conduction system is avoided (Fig 4). The tricuspid annulus is now universally flexible. The right atriotomy is closed and the heart is deaired. The aortic cross-clamp is removed. Transesophageal echocardiography is used to confirm the competence of the repair.

View larger version (67K): [in this window] [in a new window]   Fig 1. . Annular sutures extend from the posteroseptal to the anteroseptal commissure and are placed through the polyester velour band of the annuloplasty system.

View larger version (103K): [in this window] [in a new window]   Fig 2. . The annuloplasty system is slid into position and the handle is removed from the frame.

View larger version (111K): [in this window] [in a new window]   Fig 3. . The frame is released from the band.

View larger version (77K): [in this window] [in a new window]   Fig 4. . A measured plication of the annulus adjacent to the anterior and posterior leaflets is achieved and the conduction system is not jeopardized.

	Comment

Top Footnotes Abstract Introduction Technique Comment References

 
Tricuspid valve repair using the Cosgrove-Edwards Annuloplasty System is simple, safe, and easily reproducible. It results in a measured plication of the tricuspid valve that allows physiologic motion. By plication of the annulus in the area of the anterior and posterior leaflets, valve competence is restored and the conduction system of the heart is not jeopardized as sutures are not placed in this vicinity. Postoperative studies demonstrate that a flexible annuloplasty preserves the physiologic shape and normal sphincter mechanism of the valve [3].

	Footnotes

Top Footnotes Abstract Introduction Technique Comment References

 
This product has been jointly developed by The Cleveland Clinic Foundation and Baxter Healthcare. The Cleveland Clinic Foundation has entered into a licensing agreement with Baxter Healthcare relative to this invention.

Address reprint requests to Dr Cosgrove, Department of Thoracic and Cardiovascular Surgery, The Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH 44195.

	References

Top Footnotes Abstract Introduction Technique Comment References

 

1. Kirklin JW, Pacifico AD. Surgery for acquired valvular heart disease. N Engl J Med 1973;288:194–9.
2. Breyer RH, McClenathan JH, Michaelis LL, McIntosh CL, Morrow AG. Tricuspid regurgitation: a comparison of nonoperative management, tricuspid annuloplasty, and tricuspid valve replacement. J Thorac Cardiovasc Surg 1976;72:867–74.[Abstract]
3. Chandra S, Powell K, Breburda CS, et al. Three dimensional reconstruction (shape and motion) of tricuspid annulus in normals and in patients after tricuspid annuloplasty with a flexible ring. In: Computers in cardiology. Los Alamedos, CA: IEEE Computers Society Press 1996:693–6.
4. Deloche A, Guéinon J, Fariani JM, et al. Etude anatomique des valvuloplasties rhumatismales tricuspidiennes. Application á l'étude critique des différentes méthodes d'annuloplastie. Arch Mal Coeur 1974;67:497–505.
5. Cosgrove DM III, Arcidi JM, Rodriguez L, Stewart WJ, Powell K, Thomas JD. Initial experience with the Cosgrove-Edwards Annuloplasty System. Ann Thorac Surg 1995;60:499–504.[Abstract/Free Full Text]

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): James F. McCarthy Delos M. Cosgrove, III Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by McCarthy, J. F. Articles by Cosgrove, D. M. Search for Related Content PubMed PubMed Citation Articles by McCarthy, J. F. Articles by Cosgrove, D. M., III