Tricuspid Valve Repair for Functional Tricuspid Regurgitation

Abstract

Tricuspid valve insufficiency can be caused by organic disease of the tricuspid valve (rheumatic disease, endocarditis, carcinoid, and so on); however, most tricuspid regurgitation encountered in clinical practice occurs in patients with chronic left-sided valvular lesions. Ten percent to 50% of patients with severe mitral valve dysfunction have significant tricuspid regurgitation. '3' In this situation, functional tricuspid regurgitation is attributable to pulmonary hypertension and right ventricular dilatati~n.~ Other factors that contribute to functional tricuspid insufficiency may include right ventricular-tricuspid valve disproportion with compromised function of the tricuspid valve apparatus' and depressed tricuspid annular shortening during systole. It is now generally accepted that moderate to severe functional tricuspid insufficiency should be addressed at the time of correction of left-sided valvular disease.6-8 Several surgical options have been used to treat functional tricuspid insufficiency. These include tricuspid valve replacement, bicuspidalization annuloplasty, DeVega suture annuloplasty, and ring annuloplasty (Carpentier [Baxter Healthcare, Irvine, CAI or Duran [Medtronic, Minneapolis, MN]). The first two options, tricuspid valve replacement and bicuspidalization annuloplasty, provide inferior results and should not be used in the setting of functional tricuspid regurgitation. Both the DeVega annuloplasty and the Carpentier ring annuloplasty provide excellent treatment of functional tricuspid reg~rgitation.~> ~-~ However, studies suggest that repair durability is better with the Carpentier annuloplasty, particularly in the setting of severe pulmonary hypertension.6*8 Other potential disadvantages of the DeVega annuloplasty include the possibility of complete repair dehiscence from the disruption of a single stitch and obligate semicircular deformation of the tricuspid annulus, which may impair long-term valvular function.6 Drawbacks to the Carpentier ring annuloplasty include increased cost, the introduction of foreign material with the attendant risk of endocarditis, and relative rigidity of the prosthesis, which fixes the annulus in the shape of the ring. Recent advances in understanding the physiology of the tricuspid valve have provided the rationale for the use of a new annuloplasty system to correct functional tricuspid ins~fficiency.~ Computer-based analysis of echocardiographic images of the tricuspid valve shows that the tricuspid annulus is a saddle-shaped structure that has sphincter action, being smaller in systole than in diastole. Anatomic studies show that five sixths of annular dilatation takes place at the base of the anterior and posterior leaflets.6 This understanding of the normal physiology and pathoanatomy of the tricuspid valve led us to use an annuloplasty system that is universally flexible and produces a measured plication of the annulus at the base of the anterior and posterior leaflets. Repair of the tricuspid valve using the flexible Cosgrove-Edwards Annuloplasty System (Baxter Healthcare, Irvine, CA) is described.