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Tricuspid Valve Repair—Indications and Techniques: Suture Annuloplasty and Band Annuloplasty

2011; Elsevier BV; Volume: 16; Issue: 2 Linguagem: Inglês

10.1053/j.optechstcvs.2011.06.002

1532-8627

Antonio M. Calafiore, Michele Di Mauro,

Cardiac Structural Anomalies and Repair

Recently there has been new interest in the tricuspid valve, as different research identified late tricuspid regurgitation, often a consequence of uncorrected lesion during surgery, as a determinant of poor clinical outcome and even of higher late mortality.1Di Mauro M. Bivona A. Iacò A.L. et al.Mitral valve surgery for functional mitral regurgitation: prognostic role of tricuspid regurgitation.Eur J Cardiothorac Surg. 2009; 35: 635-640Crossref PubMed Scopus (59) Google Scholar, 2Calafiore A.M. Gallina S. Iacò A.L. et al.Mitral valve surgery for functional mitral regurgitation: Should moderate-or-more tricuspid regurgitation be treated? A propensity score analysis.Ann Thorac Surg. 2009; 87: 698-703Abstract Full Text Full Text PDF PubMed Scopus (111) Google Scholar However, it is still not clear when, at the first operation, functional tricuspid regurgitation has to be corrected. In most of the surgical articles, the decision to perform tricuspid valve (TV) repair during mitral valve (MV) surgery was left to the surgeon's discretion or even was not specified.2Calafiore A.M. Gallina S. Iacò A.L. et al.Mitral valve surgery for functional mitral regurgitation: Should moderate-or-more tricuspid regurgitation be treated? A propensity score analysis.Ann Thorac Surg. 2009; 87: 698-703Abstract Full Text Full Text PDF PubMed Scopus (111) Google Scholar, 3McCarthy P.M. Bhudia S.K. Rajeswaran J. et al.Tricuspid valve repair: Durability and risk factors for failure.J Thorac Cardiovasc Surg. 2004; 127: 674-685Abstract Full Text Full Text PDF PubMed Scopus (484) Google Scholar, 4Fukuda S. Gillinov A.M. McCarthy P.M. et al.Determinants of recurrent or residual functional tricuspid regurgitation after tricuspid annuloplasty.Circulation. 2006; 114: I582-I587PubMed Google Scholar, 5Ghanta R.K. Chen R. Narayanasamy N. et al.Suture bicuspidization of the tricuspid valve versus ring annuloplasty for repair of functional tricuspid regurgitation: Midterm results of 237 consecutive patients.J Thorac Cardiovasc Surg. 2007; 133: 117-126Abstract Full Text Full Text PDF PubMed Scopus (117) Google Scholar The 2008 American Heart Association/American College of Cardiology guidelines6Nishimura R.A. Carabello B.A. Faxon D.P. et al.2008 focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease.JACC. 2008; 52: e1-e142Abstract Full Text Full Text PDF Scopus (174) Google Scholar suggested to perform TV annuloplasty in patients with severe tricuspid regurgitation (TR) requiring MV surgery for MV disease (class IB); TV annuloplasty for TR less than severe should be indicated in patients undergoing MV surgery having pulmonary hypertension or tricuspid annular dilation (class IIB). The European Society of Cardiology (ESC) guidelines7Vahanian A. Baumgartner H. Bax J. et al.Guidelines on the management of valvular heart disease The Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology.Eur Heart J. 2007; 28: 230-268Crossref PubMed Scopus (1) Google Scholar suggested to perform TV annuloplasty in severe TR undergoing left-sided valve surgery (class IC) and in moderate TR with dilated annulus (maximum systolic tricuspid annulus, TA, >40 mm, 4-chamber view) in patients undergoing left-sided valve surgery (class IIA, level C). A different surgical vision was presented by Dreyfus and coworkers,8Dreyfus G.D. Corbi P.J. Chan K.M. et al.Secondary tricuspid regurgitation or dilatation: Which should be the criteria for surgical repair?.Ann Thorac Surg. 2005; 79: 127-132Abstract Full Text Full Text PDF PubMed Scopus (586) Google Scholar who suggested performing tricuspid annuloplasty regardless of the grade of trisupid regurgitation, when the tricuspid annular diameter was greater than twice the normal size (>70 mm). The measurement of TA diameter (distance between the anteroseptal commissure and the anteroposterior commissure) was performed in the operative field, when the right atrium was vertically opened, using a simple ruler. Our group9Calafiore A.M. Iacò A.L. Bivona A. et al.Echocardiographically based treatment of functional tricuspid regurgitation.J Thorac Cardiovasc Surg. 2011; (in press)Google Scholar based the decision to perform TV annuloplasty on the preoperative echocardiographic TA systolic dimensions, as TR happens in systole. We found in a cohort of 20 volunteers a median systolic TA value of 24 mm with a maximum of 28 mm; thus, we decided to perform TV annuloplasty in all cases of moderate-to-more TR and in the case of mild functional TR when systolic TA was higher than 24 mm. The results of our study demonstrated that patients with systolic TA ≤24 mm, who did not undergo TV annuloplasty besides MV surgery, did not show any increase of TR grade, at least in the mid term, whereas most of the untreated patients who showed moderate TR grade or more in the follow-up had preoperative systolic TA within the range of 25 to 28 mm. The rate of untreated patients having preoperative mild TR and systolic TA >24 mm, whose TR was impaired to moderate or more at follow-up, was 10%. However, the tricuspid valve is not only annulus, but also leaflets, chords, and papillary muscles, the position of which depends on the right ventricle size and function. Today, surgical strategies are directed mainly to the annulus or to the annulus and the leaflets, as in the Kay technique.10Kay J.H. Maselli-Campagna G. Tsuji H.K. Surgical treatment of tricuspid insufficiency.Ann Surg. 1965; 162: 53-58Crossref PubMed Scopus (180) Google Scholar Other techniques, addressed to the leaflets, can be interesting in selected cases, as the edge-to-edge technique (associated with a rigid incomplete ring or a flexible band)11De Bonis M. Lapenna E. La Canna G. et al.A novel technique for correction of severe tricuspid valve regurgitation due to complex lesions.Eur J CardioThoracic Surg. 2004; 25: 760-765Crossref PubMed Scopus (58) Google Scholar or leaflet augmentation.12Dreyfus G.D. Raja S.G. Chan K.M.J. Tricuspid leaflet augmentation to address severe tethering in functional tricuspid regurgitation.Eur J Cardiothorac Surg. 2008; 34: 908-910Crossref PubMed Scopus (116) Google Scholar These techniques, not yet standardized, are used mainly when there is excess chordal tethering, with increased coaptation depth of the tricuspid valve (the distance between the annular plane and the point where the leaflets coapt). This latter concept, not yet well investigated, was introduced by Fukuda and coworkers,4Fukuda S. Gillinov A.M. McCarthy P.M. et al.Determinants of recurrent or residual functional tricuspid regurgitation after tricuspid annuloplasty.Circulation. 2006; 114: I582-I587PubMed Google Scholar who considered a cut point for increased early failure rate of the annuloplasty, 6.8 mm, for late failure 5 mm, lower than the 10 mm identified for the mitral valve. Interestingly, these authors found a correlation between early postoperative ejection fraction 70 mm Hg. Other factors, and among them RV remodeling was one of the most important, were at the basis of the onset of more severe grade of TR. Unfortunately, as the mechanism of functional TR does not dwell only in the annulus, the surgical techniques usually applied, mainly directed to annular reduction, have fluctuating results. The RV geometry seems to be predominant in the outcome of early and late results after TV repair, but its modifications are often unpredictable, as its positive remodeling depends on multiple factors not always related to the surgical technique applied. As no technique in use today addresses the RV geometry, we are aware that the results of TV repair are not constant and are by far less predictable of the results of MV repair. Tricuspid valve annuloplasty can be performed using a suture, a strip of autologus pericardium, by means of an incomplete ring implantation, rigid or flexible (band), 3D shaped or planar. The procedure described by De Vega in 197215De Vega N.G. La anuloplastia selective regulable y permanente.Rev Esp Cardiol. 1972; 25: 555-556PubMed Google Scholar consists of a double-layer suture annuloplasty starting twice from the anteroseptal commissure and ending twice at the level of the posteroseptal commissure. The final orifice was gauged by means of 2 fingers. The surgical technique for incomplete ring or band is roughly the same. The interrupted sutures start at the level of the anteroseptal commissure and end at the level of the posteroseptal commissure or at different levels of the septal annulus. The conundrum of annular reduction for functional TR is how much the annulus has to be tightened. We prefer to remodel the annulus over a no. 25 sizer, which provides a circumference of 78.5 mm,16Frater R. Tricuspid insufficiency.J Thorac Cardiovasc Surg. 2003; 125: 9-11Abstract Full Text Full Text PDF Google Scholar but this value is largely at the surgeon's discretion. When a band annuloplasty is used, the same concept is followed.17Calafiore A.M. Iacò A.L. Contini M. et al.A single size band, 50 mm long, for tricuspid annuloplasty.Eur J Cardiothorsc Surg. 2008; 34: 677-679Crossref PubMed Scopus (7) Google Scholar The constant length of the band is 50 mm; as the sutures stop at the level of the coronary sinus, what remains is the short distance between the points A and B (Fig. 1) , roughly 30 mm.Figure 2De Vega suture annuloplasty. The pledgeted suture (2-0 Ti-cron) starts from the anteroseptal commissure and ends in front of the origin of the coronary sinus.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 3After the first suture line is completed, a second line is started close to the first one, to be ended again at the level of the coronary sinus, in such a way that the 2 suture lines are superficial or deep alternatively. The differences with the original technique described by De Vega15De Vega N.G. La anuloplastia selective regulable y permanente.Rev Esp Cardiol. 1972; 25: 555-556PubMed Google Scholar are mainly 2. The first is the suture, as we do not use a monofilament suture, which can cut the annulus, causing the “guitar chord sign,” but a 2-0 or 3-0 polyester suture. The second is where the suture ends. We go over the posteroseptal commissure to the septal annulus in front of the coronary sinus, including the entire free wall of the right ventricle, avoiding further annular dilation in this part of the annulus.View Large Image Figure ViewerDownload Hi-res image Download (PPT) We herein describe the 2 surgical techniques of tricuspid annuloplasty, which we constantly use in our experience. How to repair functional tricuspid regurgitation is still a work in progress. Techniques at our disposal are mainly addressed to the annulus, and De Vega suture annuloplasty and band annuloplasty are the most used. The decision to perform a De Vega procedure or a ring–band implantation is more often related to the single surgeon's choice. We reported an echocardiography-based decision-making to establish whether De Vega is indicated or not. In the case of a moderate-or-more functional tricuspid regurgitation (FTR) grade with systolic TA up to 28 mm, De Vega was indicated, whereas the band was implanted for systolic TA dimensions higher than 28 mm. In the case of mild FTR, De Vega was performed with systolic TA 25 to 28 mm and the band was implanted when systolic TA was higher than 28 mm.9Calafiore A.M. Iacò A.L. Bivona A. et al.Echocardiographically based treatment of functional tricuspid regurgitation.J Thorac Cardiovasc Surg. 2011; (in press)Google Scholar