Rationale and surgical strategy for concomitant tricuspid repair
2020; Elsevier BV; Volume: 3; Linguagem: Inglês
10.1016/j.xjon.2020.05.009
ISSN2666-2736
Autores Tópico(s)Cardiac Structural Anomalies and Repair
ResumoCentral MessageConcomitant tricuspid ring annuloplasty prevents moderate-to-severe tricuspid regurgitation, which otherwise occurs in a 25% to 30% of patients after isolated mitral repair.See Commentaries on pages 62 and 64. Concomitant tricuspid ring annuloplasty prevents moderate-to-severe tricuspid regurgitation, which otherwise occurs in a 25% to 30% of patients after isolated mitral repair. See Commentaries on pages 62 and 64. Feature Editor's Note—The tricuspid has oft been the forgotten valve. When it comes to intervention for secondary tricuspid regurgitation (TR), the approach has historically been conservative, with the expectation that TR would reverse with correction of mitral regurgitation. Growing evidence has shown that late symptomatic heart failure can develop secondary to residual TR after isolated mitral valve surgery for degenerative disease and that late TR is prevalent in these patients upon long-term follow-up. Recently, a more aggressive stance toward concomitant repair of the tricuspid valve at the time of mitral valve surgery for degenerative disease has been proposed, with guidelines from the American Heart Association/American College of Cardiology and European Society of Cardiology that support tricuspid repair based on the severity of TR and/or tricuspid annular size. Evolution of repair techniques from suture annuloplasty to remodeling annuloplasty with semi-rigid or rigid devices has also led to greater durability of the repair. In this issue of the Journal, Drs Chikwe and Megna review the evidence supporting concomitant tricuspid repair at the time of mitral valve surgery for degenerative disease and describe the key anatomic and physiologic changes that mediate secondary TR. The authors offer a robust discussion regarding the types of surgical repair strategies and their relative strengths and weaknesses. While catheter-based valvular interventions are gaining momentum for left-sided valvular lesions, devices for tricuspid repair remain in their infancy and their relative role for correction of secondary TR remains small. For the practicing cardiac surgeon, these authors provide a framework with the when, why, and how to manage the tricuspid valve at the time of mitral valve surgery for degenerative disease. Leora B. Balsam, MD Secondary or functional tricuspid regurgitation is commonly seen in the settings of right ventricular dilation or dysfunction, pulmonary hypertension, and left-heart dysfunction and is characterized by structurally normal tricuspid valve leaflets and subvalvular apparatus.1Nishimura R.A. Otto C.M. Bonow R.O. Carabello B.A. Erwin III, J.P. Guyton R.A. et al.2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.J Am Coll Cardiol. 2014; 63: e57-e185Crossref PubMed Scopus (2094) Google Scholar,2Falk V. Baumgartner H. Bax J.J. De Bonis M. Hamm C. Holm P.J. et al.Corrigendum to '2017 ESC/ACTS Guidelines for the management of valvular heart disease' [Eur J Cardiothorac Surg. 2017;52:616–664].Eur J Cardiothorac Surg. 2017; 52: 832Crossref Scopus (9) Google Scholar In the 1960s, observations that functional tricuspid regurgitation sometimes improved after mitral surgery led Braunwald and colleagues3Braunwald N.S. Ross Jr., J. Morrow A.G. Conservative management of tricuspid regurgitation in patients undergoing mitral valve replacement.Circulation. 1967; 35: I63-I69Crossref PubMed Google Scholar to recommend conservative management of functional tricuspid regurgitation, which remained the accepted approach for decades. Although Carpentier and colleagues4Carpentier A. Deloche A. Hanania G. Forman J. Sellier P. Piwnica A. et al.Surgical management of acquired tricuspid valve disease.J Thorac Cardiovasc Surg. 1974; 67: 53-65Abstract Full Text PDF PubMed Google Scholar stated in 1974 that a conservative approach to concomitant tricuspid repair could be "dangerous," it took another decade for the impact of severe heart failure due to tricuspid regurgitation years after isolated mitral surgery and the high mortality associated with reoperative tricuspid surgery to be widely recognized.1Nishimura R.A. Otto C.M. Bonow R.O. Carabello B.A. Erwin III, J.P. Guyton R.A. et al.2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.J Am Coll Cardiol. 2014; 63: e57-e185Crossref PubMed Scopus (2094) Google Scholar,2Falk V. Baumgartner H. Bax J.J. De Bonis M. Hamm C. Holm P.J. et al.Corrigendum to '2017 ESC/ACTS Guidelines for the management of valvular heart disease' [Eur J Cardiothorac Surg. 2017;52:616–664].Eur J Cardiothorac Surg. 2017; 52: 832Crossref Scopus (9) Google Scholar,5King R.M. Schaff H.V. Danielson G.K. Gersh B.J. Orszulak T.A. Piehler J.M. et al.Surgery for tricuspid regurgitation late after mitral valve replacement.Circulation. 1984; 70: I193-I197PubMed Google Scholar Current consensus guideline recommendations recommend concomitant tricuspid valve repair at time of degenerative mitral repair for moderate tricuspid regurgitation or tricuspid annular dilatation (Table 1), based on superior long-term clinical and echocardiographic outcomes with this strategy and evidence suggesting that a conservative approach is associated with residual and recurrent moderate-to-severe tricuspid regurgitation rates as high as 30% at 5 years.1Nishimura R.A. Otto C.M. Bonow R.O. Carabello B.A. Erwin III, J.P. Guyton R.A. et al.2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.J Am Coll Cardiol. 2014; 63: e57-e185Crossref PubMed Scopus (2094) Google Scholar,2Falk V. Baumgartner H. Bax J.J. De Bonis M. Hamm C. Holm P.J. et al.Corrigendum to '2017 ESC/ACTS Guidelines for the management of valvular heart disease' [Eur J Cardiothorac Surg. 2017;52:616–664].Eur J Cardiothorac Surg. 2017; 52: 832Crossref Scopus (9) Google Scholar There remains controversy and wide practice variation in the approach to concomitant tricuspid repair.6David T.E. David C. Manlhiot C. Fan C.S. Tricuspid regurgitation is uncommon after mitral valve repair for degenerative disease.J Thorac Cardiovasc Surg. 2017; 154: 110-122Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar, 7Dion R. Is the air in Toronto, Rochester and Cleveland different from that in London, Monaco, Leiden, Genk, Milan and New York?.J Thorac Cardiovasc Surg. 2015; 150: 1040-1043Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar, 8Chikwe J. Adams D.H. The donkey's shadow.J Thorac Cardiovasc Surg. 2017; 154: 125-126Abstract Full Text Full Text PDF Scopus (2) Google Scholar, 9McCarthy P.M. Evolving approaches to tricuspid valve surgery: moving to Europe?.J Am Coll Cardiol. 2015; 65: 1939-1940Crossref PubMed Scopus (4) Google Scholar, 10David T.E. Invited commentary: outcomes of guideline directed concomitant annuloplasty for functional tricuspid regurgitation.Ann Thorac Surg. 2020; 109: P1232-P1233Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar The aim of this review is to provide a concise account of the rationale and optimal surgical technique for concomitant tricuspid repair based on current evidence.Table 1Current consensus guideline recommendations for concomitant tricuspid repair from the American Heart Association/American College of Cardiology (AHA/ACC) and the European Society of Cardiology (ESC)AHA/ACC guidelinesESC guidelinesTricuspid valve surgery is recommended for patients with severe TR undergoing left-sided valve surgery. Class I (Level of Evidence C)Surgery is indicated in patients with severe secondary TR under-going left-sided valve surgery. Class I (Level of Evidence C)Tricuspid valve repair can be beneficial for patients with mild, moderate, or greater functional TR at the time of left-sided valve surgery with either (1) tricuspid annular dilatation or (2) previous evidence of right heart failure. Class IIa (Level of Evidence B)Surgery should be considered in patients with mild or moderate secondary TR with a dilated annulus (>40 mm or >21 mm/m2 by 2-dimensional echocardiography) undergoing left-sided valve surgery. Class IIa (Level of Evidence C)Tricuspid valve repair may be considered for patients with moderate functional TR (stage B) and pulmonary artery hypertension at the time of left-sided valve surgery Class IIb (Level of Evidence C)Surgery may be considered in patients undergoing left-sided valve surgery with mild or moderate secondary tricuspid regurgitation even in the absence of annular dilatation when previous recent right-heart failure has been documented. Class IIb (Level of Evidence C)TR, Tricuspid regurgitation. Open table in a new tab TR, Tricuspid regurgitation. The tricuspid valve annulus is saddle-shaped and characterized by the lack of a fibrous skeleton: consequently, it is very flexible, distensible, and fragile. The anterior annulus is in close proximity to 3 structures at risk during annuloplasty: the right and noncoronary sinuses of the aortic root at about 10'o clock, the right coronary artery as it runs in the atrioventricular groove between 11 and 2'o clock, and the atrioventricular conduction tissue, which lies in close proximity to the anteroseptal commissure at 7'o clock (Figures 1 and 2). The septal annulus is supported by the musculature of the interventricular septum and is least subject to dilation, which disproportionately affects the posterior and anterior annulus11Deloche A. Guerinon J. Fabiani J.M. Anatomical study of rheumatic valvulopathies. Applications to the critical study of various methods of annuloplasty.Arch Mal Coeur Vaiss. 1974; 67: 497-505PubMed Google Scholar (Figure 3). Annuloplasty rings are therefore deliberately designed as incomplete rings, to facilitate remodeling annuloplasty of the anterior and posterior annulus while avoiding suture placement in the region of conduction tissue and bundle of His.Figure 2Surgical anatomy of the tricuspid valve, viewed through a right atriotomy (the superior and inferior vena cava orifices lie to the lower left and right of the image, respectively).View Large Image Figure ViewerDownload (PPT)Figure 3Annular dilatation predominantly affects the anterior and posterior annulus.View Large Image Figure ViewerDownload (PPT) Three factors contribute to functional tricuspid regurgitation: tricuspid annular dilatation, right ventricular dysfunction and dilatation, and pulmonary hypertension. Echocardiographic analysis has suggested that functional tricuspid regurgitation is most strongly associated with tricuspid annular dilatation, whereas pulmonary hypertension and right ventricular dilatation are weaker predictors of functional tricuspid regurgitation.12Sagie A. Schwammenthal E. Padial L.R. Vazquez de Prada J.A. Weyman A.E. Levine R.A. Determinants of functional tricuspid regurgitation in incomplete tricuspid valve closure: Doppler color flow study of 109 patients.J Am Coll Cardiol. 1994; 24: 446-453Crossref PubMed Scopus (156) Google Scholar However, recent data in a long-term surgical cohort suggest that preoperative tricuspid regurgitation grade is a more important predictor of postoperative tricuspid regurgitation after degenerative mitral repair than annular dilatation.13David T.E. David C.M. Manlhiot C. Tricuspid annulus diameter does not predict the development of tricuspid regurgitation after mitral valve repair for mitral regurgitation due to degenerative diseases.J Thorac Cardiovasc Surg. 2018; 155: 2429-2436Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar Three-dimensional echocardiography in patients with functional tricuspid regurgitation reveals that the annulus tends to be dilated and flatter, with abnormal annular contraction, compared with the normal saddle-shaped annulus.14Ton-Nu T.T. Levine R.A. Handschumacher M.D. Dorer D.J. Yosefy C. Fan D. et al.Geometric determinants of functional tricuspid regurgitation: insights from 3-dimensional echocardiography.Circulation. 2006; 114: 143-149Crossref PubMed Scopus (271) Google Scholar A key part of surgical strategy is therefore correcting tricuspid annular dilatation with a remodeling annuloplasty that restores the 3-dimensional annular geometry and corrects annular dilatation. Elevated left atrial pressures in patients with advanced left-sided heart disease are transmitted to the lungs, causing pulmonary hypertension and right ventricular pressure overload, eventually with permanent pulmonary vascular remodeling. This can result in tricuspid regurgitation either directly, or indirectly as a result of right ventricular dilatation and leaflet tethering, which are predictive of functional tricuspid regurgitation severity.15Kwon D.A. Park J.S. Chang H.J. Kim Y.J. Sohn D.W. Kim K.B. et al.Prediction of outcome in patients undergoing surgery for severe tricuspid regurgitation following mitral valve surgery and role of tricuspid annular systolic velocity.Am J Cardiol. 2006; 98: 659-661Abstract Full Text Full Text PDF PubMed Scopus (93) Google Scholar Consequently, in order for isolated mitral repair to reduce or eliminate tricuspid regurgitation, reverse remodeling of both the dilated right ventricle and pulmonary vascular is needed, which takes months to years and may not occur in the presence of residual tricuspid regurgitation, or residual left-sided ventricular dysfunction or valve lesions. Finally, septal leaflet tethering may contribute to tricuspid regurgitation even in the absence of right ventricular dysfunction or pulmonary hypertension.16Matsuyama K. Matsumoto M. Sugita T. Nishizawa J. Tokuda Y. Matsuo T. Predictors of residual tricuspid regurgitation after mitral valve surgery.Ann Thorac Surg. 2003; 75: 1826-1828Abstract Full Text Full Text PDF PubMed Scopus (192) Google Scholar The mechanism may be due to left ventricular dysfunction, since the ventricles are interdependent at the septum, and left ventricular septal dysfunction also causes dysfunction of the septal wall of the right ventricular septum where the papillary muscles and chordae to the tricuspid valve septal leaflet arise. Concomitant tricuspid repair confers both prognostic and symptomatic benefit in patients with severe tricuspid regurgitation documented on preoperative or intraoperative echocardiography.1Nishimura R.A. Otto C.M. Bonow R.O. Carabello B.A. Erwin III, J.P. Guyton R.A. et al.2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.J Am Coll Cardiol. 2014; 63: e57-e185Crossref PubMed Scopus (2094) Google Scholar,2Falk V. Baumgartner H. Bax J.J. De Bonis M. Hamm C. Holm P.J. et al.Corrigendum to '2017 ESC/ACTS Guidelines for the management of valvular heart disease' [Eur J Cardiothorac Surg. 2017;52:616–664].Eur J Cardiothorac Surg. 2017; 52: 832Crossref Scopus (9) Google Scholar Given the dynamic nature of tricuspid regurgitation, the absence of severe tricuspid regurgitation on pre-bypass transesophageal echocardiography should not necessarily change the intent to perform concomitant tricuspid repair if severe tricuspid regurgitation was documented on preoperative echocardiography. This is because severe tricuspid regurgitation is usually associated with right ventricular dysfunction and dilatation and is unlikely to see significant and sustained improvement with isolated mitral repair. The role of concomitant tricuspid repair in the setting of moderate or lesser degrees of tricuspid regurgitation is less clear cut: the primary goal is to prevent progression in those patients at increased risk of severe tricuspid regurgitation. Moderate-to-severe tricuspid regurgitation is very common after isolated mitral valve surgery, even in patients with mild or no tricuspid regurgitation at baseline.17Yilmaz O. Suri R.M. Dearani J.A. Yilmaz O. Suri R.M. Dearani J.A. et al.Functional tricuspid regurgitation at the time of mitral repair for degenerative leaflet prolapse: the case for a selective approach.J Thorac Cardiovasc Surg. 2011; 142: 608-613Abstract Full Text Full Text PDF PubMed Scopus (114) Google Scholar, 18Dreyfus G.D. Corbi P.J. Chan K.M. Bahrami T. Secondary tricuspid regurgitation or dilatation: which should be the criteria for surgical repair?.Ann Thorac Surg. 1990; 49: 706-711Abstract Full Text PDF PubMed Scopus (188) Google Scholar, 19David T.E. David C.M. Tsang W. Lafreniere-Roula M. Manlhiot C. Long-term results of mitral valve repair for regurgitation due to leaflet prolapse.J Am Coll Cardiol. 2019; 74: 1044-1053Crossref PubMed Scopus (98) Google Scholar It is associated with worse right-sided remodeling, functional outcomes, and survival.17Yilmaz O. Suri R.M. Dearani J.A. Yilmaz O. Suri R.M. Dearani J.A. et al.Functional tricuspid regurgitation at the time of mitral repair for degenerative leaflet prolapse: the case for a selective approach.J Thorac Cardiovasc Surg. 2011; 142: 608-613Abstract Full Text Full Text PDF PubMed Scopus (114) Google Scholar, 18Dreyfus G.D. Corbi P.J. Chan K.M. Bahrami T. Secondary tricuspid regurgitation or dilatation: which should be the criteria for surgical repair?.Ann Thorac Surg. 1990; 49: 706-711Abstract Full Text PDF PubMed Scopus (188) Google Scholar, 19David T.E. David C.M. Tsang W. Lafreniere-Roula M. Manlhiot C. Long-term results of mitral valve repair for regurgitation due to leaflet prolapse.J Am Coll Cardiol. 2019; 74: 1044-1053Crossref PubMed Scopus (98) Google Scholar One of the first large, retrospective studies to demonstrate the impact of a conservative approach to concomitant tricuspid surgery showed that the prevalence of moderate or severe tricuspid regurgitation in 5-year follow-up after isolated degenerative mitral repair was close to 30%, compared with 16.5% at baseline.17Yilmaz O. Suri R.M. Dearani J.A. Yilmaz O. Suri R.M. Dearani J.A. et al.Functional tricuspid regurgitation at the time of mitral repair for degenerative leaflet prolapse: the case for a selective approach.J Thorac Cardiovasc Surg. 2011; 142: 608-613Abstract Full Text Full Text PDF PubMed Scopus (114) Google Scholar More recently, David and colleauges19David T.E. David C.M. Tsang W. Lafreniere-Roula M. Manlhiot C. Long-term results of mitral valve repair for regurgitation due to leaflet prolapse.J Am Coll Cardiol. 2019; 74: 1044-1053Crossref PubMed Scopus (98) Google Scholar reported moderate or severe tricuspid regurgitation rates of 21% in 20-year follow-up, compared with 4% at baseline. Moderate tricuspid regurgitation is associated with significantly worse survival: in a series of 5223 patients followed over 10 years, greater mortality was observed in patients with moderate tricuspid regurgitation compared with mild or, no regurgitation, even after adjusting for pulmonary hypertension and left and right ventricular dysfunction.20Nath J. Foster E. Heidenreich P.A. Impact of tricuspid regurgitation on long-term survival.J Am Coll Cardiol. 2004; 43: 405-409Crossref PubMed Scopus (1079) Google Scholar About one half of the patients who develop severe tricuspid regurgitation report symptoms of heart failure.1Nishimura R.A. Otto C.M. Bonow R.O. Carabello B.A. Erwin III, J.P. Guyton R.A. et al.2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.J Am Coll Cardiol. 2014; 63: e57-e185Crossref PubMed Scopus (2094) Google Scholar The mortality of reoperative tricuspid valve surgery is relatively high and associated with a high rate of persistent or recurrent heart failure and continued elevated risk of death.21Kilic A. Saha-Chaudhuri P. Rankin J.S. Conte J.V. Trends and outcomes of tricuspid valve surgery in North America: an analysis of more than 50,000 patients from the Society of Thoracic Surgeons database.Ann Thorac Surg. 2013; 96: 1546-1552Abstract Full Text Full Text PDF PubMed Scopus (207) Google Scholar Surgery and increasingly transcatheter repair may be offered to these patients, but the impact on survival and even symptoms at this late stage is unpredictable. Concomitant tricuspid repair has been associated with significantly better functional outcomes in patients compared with those undergoing isolated mitral repair.22Chikwe J. Itagaki S. Anyanwu A. Adams D.H. Impact of concomitant tricuspid annuloplasty on tricuspid regurgitation, right ventricular function and pulmonary artery hypertension after repair of mitral valve prolapse.J Am Coll Cardiol. 2015; 65: 1931-1938Crossref PubMed Scopus (195) Google Scholar Improved right ventricular remodeling and freedom from right ventricular dysfunction and pulmonary hypertension have also been associated with concomitant tricuspid repair compared with isolated mitral repair.22Chikwe J. Itagaki S. Anyanwu A. Adams D.H. Impact of concomitant tricuspid annuloplasty on tricuspid regurgitation, right ventricular function and pulmonary artery hypertension after repair of mitral valve prolapse.J Am Coll Cardiol. 2015; 65: 1931-1938Crossref PubMed Scopus (195) Google Scholar Functional tricuspid regurgitation is highly dynamic and may vary widely in the same patient depending on volume loading and hemodynamic conditions.1Nishimura R.A. Otto C.M. Bonow R.O. Carabello B.A. Erwin III, J.P. Guyton R.A. et al.2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.J Am Coll Cardiol. 2014; 63: e57-e185Crossref PubMed Scopus (2094) Google Scholar Specifically, tricuspid regurgitation may be downgraded in fasted patients under general anesthesia, so the pre-bypass transesophageal echocardiogram can be less reliable measure of tricuspid regurgitation than preoperative transthoracic echocardiography. This is one reason why assessment of annular dilatation is an important factor in the decision to perform concomitant tricuspid repair. Carpentier first described direct intraoperative assessment of annular dilation by comparing the tricuspid leaflet surface area with the diameter of the annulus (Figure 4).4Carpentier A. Deloche A. Hanania G. Forman J. Sellier P. Piwnica A. et al.Surgical management of acquired tricuspid valve disease.J Thorac Cardiovasc Surg. 1974; 67: 53-65Abstract Full Text PDF PubMed Google Scholar,26Milla F. Castillo J.G. Varghese R. Chikwe J. Anyanwu A.C. Adams D.H. Rationale and initial experience with the Tri-Ad Adams tricuspid annuloplasty ring.J Thorac Cardiovasc Surg. 2012; 143: S71-S73Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar This approach was popularized by Dreyfus and colleagues,18Dreyfus G.D. Corbi P.J. Chan K.M. Bahrami T. Secondary tricuspid regurgitation or dilatation: which should be the criteria for surgical repair?.Ann Thorac Surg. 1990; 49: 706-711Abstract Full Text PDF PubMed Scopus (188) Google Scholar who assessed tricuspid annular dilatation by direct intraoperative measurement, with a threshold for repairing of >70 mm in a flaccid heart. They subsequently acknowledged that this threshold may be too high, since one third of patients below this threshold developed moderate or severe tricuspid regurgitation during follow-up. The current consensus guideline echocardiographic threshold for significant tricuspid annular dilatation of an end-diastolic diameter of 40 mm (or >21 mm/m2) in the 4 chamber transthoracic view is somewhat arbitrary but supported by several retrospective series.1Nishimura R.A. Otto C.M. Bonow R.O. Carabello B.A. Erwin III, J.P. Guyton R.A. et al.2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.J Am Coll Cardiol. 2014; 63: e57-e185Crossref PubMed Scopus (2094) Google Scholar,2Falk V. Baumgartner H. Bax J.J. De Bonis M. Hamm C. Holm P.J. et al.Corrigendum to '2017 ESC/ACTS Guidelines for the management of valvular heart disease' [Eur J Cardiothorac Surg. 2017;52:616–664].Eur J Cardiothorac Surg. 2017; 52: 832Crossref Scopus (9) Google Scholar Three-dimensional echocardiography is probably a more accurate method of assessing dilatation of the tricuspid annulus.23Sukmawan R. Watanabe N. Ogasawara Y. Yamaura Y. Yamamoto K. Wada N. et al.Geometric changes of tricuspid valve tenting in tricuspid regurgitation secondary to pulmonary hypertension quantified by novel system with transthoracic real-time 3-dimensional echocardiography.J Am Soc Echocardiogr. 2007; 20: 470-476Abstract Full Text Full Text PDF PubMed Scopus (78) Google Scholar Concomitant repair is most easily performed via an oblique right atriotomy on the arrested heart before mitral or aortic valve reconstruction, with direct bicaval cannulation and caval snares or vacuum-assisted venous drainage. The right atrium can be very fragile, and the risk of tearing into the atrioventricular groove is minimized by starting the atriotomy incision well away from the groove and avoiding aggressive retraction. As long as there is no patent foramen ovale or atrial septal defect, tricuspid repair can also safely be performed on the beating heart without the crossclamp to minimize ischemia time, although greater care with suture placement is required to avoid annular tears (Figure 5). Vacuum-assisted venous drainage removes the need to snare the vena cavae. The pulmonary artery catheter may be retracted to one side or temporarily placed in the right atrium to facilitate suture placement. There are 2 main approaches to repair of tricuspid regurgitation: ring annuloplasty and suture annuloplasty (most commonly DeVega repair) (Table 2).22Chikwe J. Itagaki S. Anyanwu A. Adams D.H. Impact of concomitant tricuspid annuloplasty on tricuspid regurgitation, right ventricular function and pulmonary artery hypertension after repair of mitral valve prolapse.J Am Coll Cardiol. 2015; 65: 1931-1938Crossref PubMed Scopus (195) Google Scholar, 23Sukmawan R. Watanabe N. Ogasawara Y. Yamaura Y. Yamamoto K. Wada N. et al.Geometric changes of tricuspid valve tenting in tricuspid regurgitation secondary to pulmonary hypertension quantified by novel system with transthoracic real-time 3-dimensional echocardiography.J Am Soc Echocardiogr. 2007; 20: 470-476Abstract Full Text Full Text PDF PubMed Scopus (78) Google Scholar, 24McCarthy P.M. Bhudia S.K. Rajeswaran J. Hoercher K.J. Lytle B.W. Cosgrove D.M. 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 (549) Google Scholar,36Ghata R.K. Chen R. Narayanaswamy N. McGurk S. Lipsitz S. Chen F.Y. et al.Suture bicuspidization of the tricuspid valve versus ring annuloplasty for repair of tricuspid regurgitation: midterm results of 237 consecutive patients.J Thorac Cardiovasc Surg. 2007; 133: 117-126Abstract Full Text Full Text PDF Scopus (133) Google Scholar Both techniques aim to correct and prevent anterior and posterior annular dilatation, and avoid suture placement in the region of conduction tissue to minimize the risk of heart block. Ring annuloplasty, where the annulus is remodeled or permanently fixed in a systolic position by suturing in a rigid or semi-rigid ring, has been associated with significantly greater durability of tricuspid repair compared with suture annuloplasty, where the annulus size is reduced by using a continuous suture to "purse string" the annulus (Figure 6, A).24McCarthy P.M. Bhudia S.K. Rajeswaran J. Hoercher K.J. Lytle B.W. Cosgrove D.M. 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 (549) Google Scholar The purse-string is prone to cutting out of the fragile annulus and associated with high rates of residual and recurrent tricuspid regurgitation. Simple horizontal mattress sutures are placed close together, approximately 1 cm wide, 2 to 3 mm deep, and 1 to 2 mm outside the hinge-point between the leaflet and the atrial wall. The DeVega suture annuloplasty is usually performed with a running suture taken from the septal annulus just above the coronary sinus, to the anteroseptal commissure and back again with a distance of about 5 mm between the 2 arms, and buttressed at the far ends with pledgets.Table 2Comparison of annuloplasty techniques for functional TRAnnuloplasty techniqueReduction annuloplastyRemodeling annuloplastyBicuspidizationDeVegaFlexible bandSemi-rigid ringRigid ringSutureBandRingProsthesesIndicationLimitedMild TRMild TRMild-moderate TRModerate-severe TRAnnular stabilizationPosteriorAnteroposteriorAnteroposteriorAnteroposterior and septalAnteroposterior and septalDurabilityPoor 25% moderate or severe TR at 3 y36Ghata R.K. Chen R. Narayanaswamy N. McGurk S. Lipsitz S. Chen F.Y. et al.Suture bicuspidization of the tricuspid valve versus ring annuloplasty for repair of tricuspid regurgitation: midterm results of 237 consecutive patients.J Thorac Cardiovasc Surg. 2007; 133: 117-126Abstract Full Text Full Text PDF Scopus (133) Google ScholarPoor to moderate 28% 3+ or 4+ TR at 5 y24McCarthy P.M. Bhudia S.K. Rajeswaran J. Hoercher K.J. Lytle B.W. Cosgrove D.M. 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 Sco
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