Ann Thorac Surg 2007;83:698-699
© 2007 The Society of Thoracic Surgeons
How To Do It
Adjustable Segmental Tricuspid Annuloplasty: A New Modified Technique
Anas Sarraj, MD, FETCS*,
Juan Duarte, MD, PhD
Department of Cardiovascular Surgery, Hospital Universitario de la Princesa, Autonoma University, Madrid, Spain
Accepted for publication April 6, 2006.
* Address correspondence to Dr Sarraj, Department of Cardiovascular Surgery, Hospital Universitario de la Princesa, Diego de León, 62, Madrid, 28006 Spain (Email: anas_sarraj{at}hotmail.com).
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Abstract
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Adjustable segmental tricuspid annuloplasty is a new modified technique that tries to reduce the incidence of failure in De Vega annuloplasty and adjusts and distributes the pursing forces in the more dilated area.
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Introduction
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Trying to reduce the incidence of failure after De Vega tricuspid annuloplasty [1] for functional annular dilatation, we have introduced a new modified technique that simplifies other surgical alternatives previously described by Antunes [2] and Revuelta [3].
Between March and November 2005, 7 female patients (mean age, 66.2 ± 7.4 years; range, 59 to 74 years) with severe rheumatic mitral valve lesion, functional tricuspid insufficiency, and no severe pulmonary hypertension, underwent mitral valve replacement and adjustable segmental tricuspid annuloplasty.
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Technique
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In the beating heart, and after the tricuspid valve has been carefully explored, the tricuspid annulus is identified, and the distance between anteroseptal and posteroseptal commissures is measured using a 32 or 34 Carpentier tricuspid valve annuloplasty sizer. A 2-0 Ethibond suture with a Teflon pledget is used for the first double suture line. It is placed in the region of the posteroseptal commissure and passed along the annulus where the posterior leaflet is attached, while the second suture is placed in the region of the anteroseptal commissure and passed along the annulus where the anterior leaflet is attached. The two separate sutures are met in the middle, near the anteroposterior commissure, and are supported together by wider pledged pointing to the 12-o’clock position. Then they are passed through a short rubber tourniquet to equalize the pursing force in both ends of the same suture and to adjust it in each one. The tourniquets are taken down to touch the tricuspid annulus and both sutures are marked with a small vascular clip just above the tourniquet (Fig 1A). The pulmonary artery is cross-clamped and a warm saline solution is injected into the right ventricle through the tricuspid valve, while the first suture is pursed over until achieving the coaptation of the anterior tricuspid leaflet with the others, the middle pledget turning clockwise and pointing to the 1-o’clock position up and the anterolateral commissure down (Fig 1B). The second suture should be pursed almost one-third of what we have done in the first one (ie, the correlation between the anterior and posterior annular dilatation) [4]. The corresponding Carpentier tricuspid valve annuloplasty sizer is introduced again in the tricuspid annulus to prevent tricuspid stenosis by overcorrection. The pulmonary artery is declamped, the vascular clips are taken off, and the sutures are sequentially tightened. The competency of the tricuspid valve is tested again as previously described. After weaning off cardiopulmonary bypass, intraoperative Doppler echocardiography is done to assess the competency of the tricuspid valve.
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Fig 1. Adjustable segmental tricuspid annuloplasty. (A) Tricuspid annular dilatation, particularly in the dotted area corresponding to the anterior leaflet and posterior leaflet. (B) Completed adjustable segmental annuloplasty. (A = anterior leaflet; AVN = atrioventricular node; CS = coronary sinus; P = posterior leaflet; S = septal leaflet).
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Six months after surgery, Doppler echocardiography was performed in all these patients demonstrating no recurrence of tricuspid regurgitation or residual stenosis by overcorrection.
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Comment
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Herein, we have used two separate sutures, and we have chosen the middle point between the anteroseptal commissure and posteroseptal commissure to perform the pursestring technique. These new modifications make the technique more selective in the remodeling of the tricuspid annulus. It could achieve better coaptation of the anterior leaflet with the others, successful annular reduction, better adjustment, and distribution of pursing force in the more dilated region (Fig 1A, dotted area). It could prevent massive insufficiency caused by one suture tear from the endocardium, and prevent the tear of the endocardium in the posteroseptal region, which could be produced in the De Vega technique by pursing in an opposite direction.
We recommend this modified technique in selected cases, such as functional tricuspid insufficiency not associated with severe pulmonary hypertension (> 60 mm Hg) or severe dilatation of tricuspid annulus (index annulus dimension > 21 mm/m2). We are awaiting the long-term results of this modified procedure in a larger series of patients.
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References
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- De Vega NF. La anuloplastia selectiva, regulable y permanente Rev Esp Cardiol 1972;25:555-556.[Medline]
- Antunes MJ, Girdwood RW. Tricuspid annuloplasty: a modified technique Ann Thorac Surg 1983;35:676-678.[Abstract/Free Full Text]
- Revuelta JM, Garcia-Rinaldi R. Segmental tricuspid annuloplasty: a new technique(letter) J Thorac Cardiovasc Surg 1989;97:799-801.[Medline]
- Deloche A, Guérinon J, Fariani JN, et al. Anatomical study of rheumatic tricuspid valvulopathiesApplications to the critical study of various methods of annuloplasty. [in French] Arch Mal Coeur 1974;67:497-505.
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A. Sarraj, J.-M. Nuche, L. Dominguez, L.-M. Garcia, G. Reyes, J. Bustamante, P. Alvarez, and J. Duarte
Adjustable Segmental Tricuspid Annuloplasty: Technical Advantages and Midterm Results
Ann. Thorac. Surg.,
April 1, 2009;
87(4):
1148 - 1153.
[Abstract]
[Full Text]
[PDF]
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Abstract
Introduction
