Antonio Maria Calafiore, MD, Michele Di Mauro, MD

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Presentation transcript:

Tricuspid Valve Repair—Indications and Techniques: Suture Annuloplasty and Band Annuloplasty Antonio Maria Calafiore, MD, Michele Di Mauro, MD Operative Techniques in Thoracic and Cardiovascular Surgery Volume 16, Issue 2, Pages 86-96 (June 2011) DOI: 10.1053/j.optechstcvs.2011.06.002 Copyright © 2011 Elsevier Inc. Terms and Conditions

Figure 1 Anatomic view of the tricuspid valve. The annulus is enlarged. The anterior and septal leaflets are represented more than the posterior. The suture line, both in De Vega suture annuloplasty and in band annuloplasty, starts from A (the anteroseptal commissure, AS commissure) and ends in B (in front of the origin of the coronary sinus, CS). The portion of the septal leaflet included from CS and the posteroseptal commissure (PS commissure) is part of the free wall of the right ventricle. P1, P2, and P3 represent the papillary muscles, which are not as constant in number and position as in the mitral valve apparatus. AP = anteroposterior. Operative Techniques in Thoracic and Cardiovascular Surgery 2011 16, 86-96DOI: (10.1053/j.optechstcvs.2011.06.002) Copyright © 2011 Elsevier Inc. Terms and Conditions

Figure 2 De 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. Operative Techniques in Thoracic and Cardiovascular Surgery 2011 16, 86-96DOI: (10.1053/j.optechstcvs.2011.06.002) Copyright © 2011 Elsevier Inc. Terms and Conditions

Figure 3 After 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 Vega15 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. Operative Techniques in Thoracic and Cardiovascular Surgery 2011 16, 86-96DOI: (10.1053/j.optechstcvs.2011.06.002) Copyright © 2011 Elsevier Inc. Terms and Conditions

Figure 4 Both needles of the same suture are passed into a pledget. Operative Techniques in Thoracic and Cardiovascular Surgery 2011 16, 86-96DOI: (10.1053/j.optechstcvs.2011.06.002) Copyright © 2011 Elsevier Inc. Terms and Conditions

Figure 5 A cylindrical sizer no. 25 (or a bigger sizer, according to the surgeon's preference) is positioned inside the tricuspid annulus and the suture is tied to be adapted to the sizer itself. Operative Techniques in Thoracic and Cardiovascular Surgery 2011 16, 86-96DOI: (10.1053/j.optechstcvs.2011.06.002) Copyright © 2011 Elsevier Inc. Terms and Conditions

Figure 6 The final result shows a tricuspid annulus reduced in the part of its circumference related to the free wall of the right ventricle (from point A to B, long distance, Fig. 1). Operative Techniques in Thoracic and Cardiovascular Surgery 2011 16, 86-96DOI: (10.1053/j.optechstcvs.2011.06.002) Copyright © 2011 Elsevier Inc. Terms and Conditions

Figure 7 Flexible band annuloplasty. The interrupted sutures (2-0 Ti-cron) start at the same point as in Fig. 2. Operative Techniques in Thoracic and Cardiovascular Surgery 2011 16, 86-96DOI: (10.1053/j.optechstcvs.2011.06.002) Copyright © 2011 Elsevier Inc. Terms and Conditions

Figure 8 The sutures end in front of the origin of the coronary sinus. Operative Techniques in Thoracic and Cardiovascular Surgery 2011 16, 86-96DOI: (10.1053/j.optechstcvs.2011.06.002) Copyright © 2011 Elsevier Inc. Terms and Conditions

Figure 9 A 50-mm band (SMB50; Sorin, Saluggia, Italy) is positioned, to reduce the tricuspid orifice to the circumference of a no. 25 sizer, as in Fig. 3. The distance not covered by sutures is approximately 30 mm (the circumference of a no. 25 sizer is 78.5 mm). Operative Techniques in Thoracic and Cardiovascular Surgery 2011 16, 86-96DOI: (10.1053/j.optechstcvs.2011.06.002) Copyright © 2011 Elsevier Inc. Terms and Conditions