Measured Tricuspid Annuloplasty: A Rapid and Reproducible Technique George E. Reed, M.D., and Luis E. Cortes, M.D. ABSTRACT A technique for repairing the tricuspid valve that involves principles successfully used in operative repair of the mitral valve is described. A measured orifice produces competence but not obstruction and eliminates the trial-and-erroraspects of annuloplasty. The procedure can be performed with the heart beating, though it can be transiently fibrillated so that the suture may be tied without tension.
While there is virtual unanimity of opinion that valve repair is the treatment of choice for tricuspid regurgitation, considerable controversy centers on how best to do this. The technique described here involves application of principles used successfully in operative repair of the mitral valve [13 with which there has been extensive good experience. The dual objective of producing competence without obstruction is best met by creation of a measured orifice. This eliminates the trial-and-error aspects of annuloplasty.
Rationale From the formulas for area (A = d)and circumference (C = 2773 it can be shown that when the circumference of a valve is 8 cm, the orifice area will be greater than 5 cm2. When the circumference is reduced to 7 cm, the valve area is about 3.8 cm2, still considerably larger than the orifices of most valve prostheses. It is therefore unnecesFrom the Department of Surgery, New York University School of Medicine, New York, NY. Accepted for publication Aug 19, 1975 Address reprint requests to Dr. Reed, Department of Surgery, New York University School of Medicine, 560 First Ave, New York, NY 10016.
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sary for the tricuspid valve to have a circumference larger than 8 cm. A valve reduced to this size will almost always be competent. In fact, this is the maximum size to which the circumference should be reduced to assure competence.
Technique Horizontal mattress sutures of No. 1Dacron are used, buttressed on each side with Teflon felt. The first bite is taken just anterior to the coronary sinus. The needle is introduced 3 mm from the annulus and describes an arc which passes beneath the annulus, encompassing a half cylinder of tissue 6 mm in diameter. The course of the needle through the annulus anteriorly describes the same arc and is introduced 8 cm (by estimation) from the first bite, as shown in the Figure. The mattress suture is then completed with the two limbs of the suture separated by a distance of 6 mm. When the suture is tied, the orifice area will be larger than 5 cmz. As noted, this can be reduced further without creating obstruction. This procedure is usually performed with the heart beating, though it can be transiently fibrillated so that the suture can be tied without tension. Generally, annuloplasty is done while the patient is being rewarmed from the moderate hypothermia used during mitral or aortic valve repair or replacement. Thus, cardiopulmonary bypass is extended for very little, if any, additional time. Reference 1. Reed GE: The repair of mitral regurgitation: an eleven year experience. Am J Cardiol31:496, 1973
169 How to Do It: Reed and Cortes: Measured Tricuspid Annuloplasty
P
sinus coronary
Technique of measured tricuspid annuloplasty.
While there is virtual unanimity of opinion that valve repair is the treatment of choice for tricuspid regurgitation, considerable controversy centers on how best to do this. The technique described here involves application of principles used successfully in operative repair of the mitral valve [13 with which there has been extensive good experience. The dual objective of producing competence without obstruction is best met by creation of a measured orifice. This eliminates the trial-and-error aspects of annuloplasty.
Rationale From the formulas for area (A = d)and circumference (C = 2773 it can be shown that when the circumference of a valve is 8 cm, the orifice area will be greater than 5 cm2. When the circumference is reduced to 7 cm, the valve area is about 3.8 cm2, still considerably larger than the orifices of most valve prostheses. It is therefore unnecesFrom the Department of Surgery, New York University School of Medicine, New York, NY. Accepted for publication Aug 19, 1975 Address reprint requests to Dr. Reed, Department of Surgery, New York University School of Medicine, 560 First Ave, New York, NY 10016.
168
sary for the tricuspid valve to have a circumference larger than 8 cm. A valve reduced to this size will almost always be competent. In fact, this is the maximum size to which the circumference should be reduced to assure competence.
Technique Horizontal mattress sutures of No. 1Dacron are used, buttressed on each side with Teflon felt. The first bite is taken just anterior to the coronary sinus. The needle is introduced 3 mm from the annulus and describes an arc which passes beneath the annulus, encompassing a half cylinder of tissue 6 mm in diameter. The course of the needle through the annulus anteriorly describes the same arc and is introduced 8 cm (by estimation) from the first bite, as shown in the Figure. The mattress suture is then completed with the two limbs of the suture separated by a distance of 6 mm. When the suture is tied, the orifice area will be larger than 5 cmz. As noted, this can be reduced further without creating obstruction. This procedure is usually performed with the heart beating, though it can be transiently fibrillated so that the suture can be tied without tension. Generally, annuloplasty is done while the patient is being rewarmed from the moderate hypothermia used during mitral or aortic valve repair or replacement. Thus, cardiopulmonary bypass is extended for very little, if any, additional time. Reference 1. Reed GE: The repair of mitral regurgitation: an eleven year experience. Am J Cardiol31:496, 1973
169 How to Do It: Reed and Cortes: Measured Tricuspid Annuloplasty
P
sinus coronary
Technique of measured tricuspid annuloplasty.
