Intro4u2u

Thirty six years have elapsed since Grondin and associates published in The Journal of Thoracic and Cardiovascular Surgery the paper “The tricuspid valve: A surgical challenge.” Since then, and probably due to it, a lot of attention was placed in a valve whose patho-physiology was not very well understood at the time.

Surgeons now know that a severe degree of tricuspid regurgitation must be corrected at the time of mitral operation, and we now have in our armamentarium several techniques that have successfully passed the test of time to achieve a competent tricuspid valve. It is also true that we don’t know why so many patients, up to 20-25% according to different experiences, whose tricuspid valve was considered quite normal at the time of surgery, later develop right ventricular failure with concomitant severe tricuspid regurgitation. Once this situation is established neither medical nor surgical treatment are clearly effective.

After more than thirty years dealing with this problem and having visually explored many tricuspid valves of rheumatic and non-rheumatic patients at the time of surgery, we have the impression that most of the rheumatic valves have some degree of pathological changes in the leaflets or the subvalvular apparatus even in the absence of any tricuspid regurgitation detectable clinically or echocardiographically.

If these changes progress with time, the valve can became slightly incompetent and trigger a vicious circle that leads to the above mentioned situation with right ventricular failure. Could this vicious circle be interrupted by fixing the annulus with any of the available techniques?

If we admit this hypothesis, surely we are going to treat some patients unnecessarily. What is the price of that? To our knowledge, to wear a pair of sutures around the tricuspid annulus does not imply any risk in the long term. The low economical cost plus the short extra time of cardiopulmonary bypass necessary to perform a suture annuloplasty are added attractions. We lack the necessary experience to decide if such a policy will be applicable using prosthetic rings. Probably the relative high cost of rings can be an obstacle, especially in third world countries where rheumatic valvular disease is most prevalent.

Some technical tricks to properly perform a De Vega tricuspid annuloplasty:

• Place the sutures before doing anything in the mitral valve. Otherwise it may be difficult to place a good stitch in the antero-septal commissure.

• Try to keep your sutures as buried in the annulus as possible by going inside again close to the point you came out.

• If you just need to fix the annulus or to slightly reduce it, you don’t need a stitch at both ends; one suture doubly passed is enough. If you need to really reduce the annulus two sutures, one starting at either end, will produce a more uniform plication.

• In some cases, when the annulus is very much dilated, the plication can be done in two or even three parts. After the left heart valve surgery is completed, with the aortic clamp released, the sutures are tied over a progressive occluder.