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We describe a tricuspid valve ring annuloplasty for a 67-year-old woman who had an extremely dilated tricuspid valve annulus. During surgery, we found that the septal segment of the annulus was dilated to 60 mm, nearly double its normal size. Therefore, a standard annuloplasty without a prosthetic ring seemed unlikely to provide the needed annular plication. We used a 28-mm prosthetic ring, about the size of a normal septal segment, to plicate it. First, 5 U-shaped sutures, with 1 at each septal commissure, were used to plicate the septal segment to its physiologic size. Next, U-shaped sutures for the posterior and anterior segments were used to reduce the length of the posterior segment much more than that of the anterior segment. The septal sutures were then passed equidistantly between 2 markers on the prosthetic ring, and the remaining sutures were passed equidistantly through the ring. Finally, the prosthetic ring was affixed to the tricuspid annulus. Echocardiography revealed trivial tricuspid valve regurgitation postoperatively. In cases of dilated tricuspid valve annulus, particularly when the septal segment is very dilated, some modification of the annuloplasty may be needed. The physiologic size of the septal segment of the tricuspid valve annulus and the relative physiologic proportions of the anterior and posterior segments should be taken into consideration.
Although several annuloplasty methods for the correction of functional tricuspid valve regurgitation (TR) have been described,1–5 there is no agreement about which is best.6 Moreover, only a few studies have evaluated the benefits of selecting an annuloplasty method by analyzing the size of each segment of the tricuspid valve annulus.1,6 Here—within the context of a case of extremely dilated tricuspid valve annulus in which there was particular dilation of the septal segment—we describe a new approach to tricuspid annuloplasty on the basis of the physiologic size of each segment of the annulus.
A 67-year-old woman was referred to our hospital with fatigability, facial edema, and abdominal swelling. She had a history (20 years earlier) of open mitral commissurotomy for mitral valve stenosis. An electrocardiogram (ECG) showed bradycardia (46 beats/min) with atrial fibrillation. Echocardiography showed severe mitral valve stenosis and severe TR in association with an extremely dilated tricuspid valve annulus (diameter, 55.7 mm), and wide gaps between the edges of the tricuspid leaflets (Fig. 1A–C). Left ventricular function was preserved, with an ejection fraction of 0.59. Upon cardiac catheterization, the pulmonary and right atrial pressures were 36/13 mmHg and 11 mmHg, respectively. During surgery, mitral valve replacement was performed first, through the superior-transseptal approach. After closing the atrial septum, we analyzed the tricuspid valve.
The leaflets of the tricuspid valve appeared almost normal, without degenerative changes; but the septal, anterior, and posterior segments of the tricuspid valve annulus were, respectively, 60, 60, and 40 mm (Fig. 1D). A standard annuloplasty, without a prosthetic ring, was unlikely to provide the appropriate annular plication, because of the extremely dilated septal segment, nearly double its normal size.6 Therefore, we selected a 28-mm prosthetic Carpentier-Edwards Physio Annuloplasty Ring (Edwards Lifesciences LLC; Irvine, Calif), smaller than the dilated septal segment, but close to its physiologic size, for plication.
First, in order to plicate the septal segment to its physiologic size, we placed 5 U-shaped septal sutures (2-0 polyester, double-armed and nonpledgeted, each approximately 12 mm in width). These 5 sutures were placed parallel to the base of the septal leaflet in order to avoid damaging the cardiac conduction system (that is, the atrioventricular node and the bundle of His)4; 1 suture was placed at the anteroseptal and 1 at the posteroseptal commissure, with the rest placed between them (Fig. 2A). Next, to reduce greatly the length of the posterior in comparison with that of the anterior segment, we placed 1 U-shaped suture at the anteroposterior commissure, 2 in the posterior segment, and 5 in the anterior segment (Fig. 2B). The septal sutures were then passed equidistantly between the 2 marks on the prosthetic ring (Fig. 2C); next, the anterior and posterior sutures were also passed equidistantly through the ring (Fig. 2D). Finally, the ring was affixed to the tricuspid annulus (Figs. 1H and and2E).2E). The patient recovered well after the operation. She did not require pacemaker implantation, because the postoperative ECG showed atrial fibrillation (90 beats/min) with a narrow QRS width. Echocardiography revealed trivial TR, a physiologic tricuspid valve diameter, and adequate postoperative coaptation of each valve leaflet (Fig. 1E–G).
Functional TR, which is often secondary to pulmonary hypertension or concomitant mitral valve disease, is most often caused by dilation of the tricuspid valve annulus.7 Many cardiac surgeons advocate tricuspid annuloplasty at the time of mitral valve surgery in patients who have moderate or severe TR.7 Several annuloplasty methods have been described, including bicuspidization2 (Fig. 3B), anterior–posterior segment annuloplasty without a prosthetic band3 (Fig. 3C), and annuloplasty using a prosthetic band or ring, which can be rigid, semi-rigid, or flexible1,4,5 (Figs. 3D and and3E).3E). However, only a few studies1 have evaluated and compared the efficacy of these techniques and their long-term outcomes. Moreover, little attention has been paid to selecting the best method on the basis of a detailed analysis of the size of each tricuspid valve segment.
In our patient, the tricuspid valve was extremely dilated, and, during the operation, we found that all 3 segments were dilated, especially the septal segment. In such a case, some modification of the annuloplasty technique on the basis of the size of the tricuspid annulus might be required to plicate the septal segment adequately and to reinstate physiologic proportions between the anterior and posterior segments.
Because the extremely dilated septal segment of the tricuspid valve annulus needed plication in our patient, neither bicuspidization2 nor anterior–posterior segment annuloplasty3 was appropriate (Figs. 3A–D). Similarly, the standard procedure using a prosthetic ring with or without opening the anteroseptal commissure, as cited by Carpentier,8,9 could not have plicated the septal segment (Fig. 3E), because the size of the prosthetic ring is usually chosen to match the patient's septal segment at the time of surgery.4,8,9 Moreover, even if TR were reduced by such procedures, the remaining tricuspid annular dilation can lead to worsening of the TR and of the New York Heart Association functional class.10 Therefore, to plicate the septal segment annulus, we selected a 28-mm ring (Fig. 3F), the most commonly used size,1 because the septal segment of a normal tricuspid valve annulus is around 30 mm.6
The physiologic proportion between the anteroposterior segment (combined anterior and posterior segments) and the septal segment was reported to be 2.43:16; however, the natural proportion of the anterior-to-posterior segment has not been defined, because the size of these segments varies greatly.11 The posterior segment is the most severely affected by tricuspid valve annular dilation (up to 80% increase in length), whereas the anterior segment is usually less affected (up to 40% increase).8 Therefore, in reconstructing the physiologic morphology, it may be better to reduce the length of the posterior segment much more than that of the anterior segment (Fig. 3G). In our patient, to reduce the length of the posterior segment disproportionately, we used 2 U-shaped sutures to affix the prosthetic ring to the posterior segment, and 5 for the anterior segment.
One potential problem with our technique is the possibility of injuring the conduction system (most specifically, the atrioventricular node and the bundle of His) while the sutures are placed in the side of the septal segment where the anteroseptal commissure lies. Therefore, we successfully applied the technique described by Carpentier8 and by Duran and Ubago4 to avoid injury to the conduction system. Briefly, in this technique the needle is passed through the base of the leaflet into the ventricular cavity and then is backed through the annulus toward the atrium.4,8
In conclusion, patients who have an extremely dilated tricuspid valve annulus need detailed analysis of the tricuspid annular size in order that the best treatment might be determined. Our technique for tricuspid valve annuloplasty in cases of extremely dilated tricuspid valve annulus (in the presence of a particularly dilated septal segment) is highly reproducible and might enable surgeons to simulate the morphology of the tricuspid valve better than was previously possible.
Address for reprints: Haruhiko Kondoh, MD, Department of Cardiovascular Surgery, Otemae Hospital, 1-5-34 Otemae, Chuo-ku, Osaka 540-0008, Japan