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Should stitch annuloplasty really be abandoned for developed flexible prosthetic band or ring in functional tricuspid regurgitation?

Bursa Yüksek Ihtisas Education and Research Hospital, Bursa 16330, Turkey

Tricuspid valve annuloplasty with a flexible prosthetic band

I read with great interest the recent article by Gatti and colleagues [1] in the ICVTS. They report satisfactory short-term clinical and echocardiographic results of tricuspid valve annuloplasty with a flexible prosthetic band (Koehler band) in 53 patients with significant tricuspid regurgitation and dilatation of the right-sided cardiac chambers. I would like to add some comments to this topic.

In cardiovascular practice, various repair techniques have been advocated in patients with functional tricuspid regurgitation secondary to left-sided valve disease, those of which include the use of flexible and rigid prosthetic rings or three-dimensional rings, flexible prosthetic bands, use of artificial chordae with polytetrafluoroethylene sutures for anterior and septal ticuspid leaflet pathology, stitch annuloplasty such as semicircular (De Vega repair) or simple lateral annuloplasty (Kay), and novel techniques such as edge-to-edge technique [2] or cover technique [3].

Selecting of the annuloplasty type is mostly a matter of surgeon choice, and the underlying valve pathology. Although the literature contains little information concerning the late results of tricuspid valve repair, I also believe that tricuspid annuloplasty preserves the geometry and function of the right ventricle and avoids complications inherent in prosthetic valve surgery. Tricuspid valve repair does not add morbidity or mortality to a leftsided valve surgery.

Currently, the most common surgical procedure performed for repairing tricuspid annular dilatation is undersized tricuspid annuloplasty resulting in increased tricuspid leaflet coaptation and decreased tricuspid regurgitation.

The subject of leaflet tethering, which results from apical and lateral displacement of the papillary muscles secondary to progressive right ventricular dilation, may not completely be solved by tricuspid annuloplasty alone and may cause late recurrence of tricuspid regurgitation. Castedo and colleagues reported that an approach including the tricuspid bicuspidalization achieved by posterior leaflet plication, a double valve orifice obtained by approximation of the free edges of the septal, and the newly created antero-posterior leaflets were very effective in patients with severe tethering effect and great annulus diameter in which DeVega's annuloplasty was previously performed.

In our clinic, in patients with very dilated tricuspid annulus and/or severe tricuspid regurgitation, we have performed ring annuloplasty techniques, but the stitch annuloplasty has been used as well for surgical correction of less pronounced enlargement of the tricuspid annulus.

In their experience compared to ring annuloplasty with a mean followup time of 3 years, Gantha and colleagues [4] suggested that bicuspidization annuloplasty was a reliable method for tricuspid annuloplasty and should be given consideration when approaching every patient with functional tricuspid regurgitation undergoing aortic or mitral valve surgery. They conclude that there is not a significant difference between two annuloplasty techniques.

Additionally, as reported in the authors' article, it makes satisfactory short-term results difficult to put in perspective for a long-term period. Therefore, I agree with the authors that longer-term evaluations are required to determine the stability of tricuspid valve repair using Koehler band.

As a conclusion, instead of implanting a prosthetic ring or band, I think that stitch annuloplasty may still be useful for the correction of moderate functional tricuspid regurgitation in patients undergoing left-sided valve surgery becauce of a simpler, inexpensive, and less time-consuming procedure with few complications.

	References

Top References

 

1. Gatti G, Marciano F, Antonini-Canterin F, Pinamonti B, Benussi B, Pappalardo A, Zingone B. Tricuspid valve annuloplasty with a flexible prosthetic band. Interact CardioVasc Thorac Surg 2007; 6:731–736.[Abstract/Free Full Text]
2. Castedo E, Cañas A, Cabo RA, Burgos R, Ugarte J. Edge-to-edge tricuspid repair for redeveloped valve incompetence after DeVega's annuloplasty. Ann Thorac Surg 2003; 75:605–606.[Abstract/Free Full Text]
3. De Bonis M, Lapenna E, La Canna G, Grimaldi A, Maisano F, Torraca L, Caldarola A, Alfieri O. A novel technique for correction of severe tricuspid valve regurgitation due to complex lesions. Eur J Cardiothorac Surg 2004; 25:760–765.[Abstract/Free Full Text]
4. Ghanta RK, Chen R, Narayanasamy N, McGurk S, Lipsitz S, Chen FY, Cohn LH. Suture bicuspidization of the tricuspid valve versus ring annuloplasty for repair of functional tricuspid regurgitation: midterm results of 237 consecutive patients. J Thorac Cardiovasc Surg 2007; 133:117–126.[Abstract/Free Full Text]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Senol Yavuz Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Yavuz, S. Search for Related Content PubMed PubMed Citation Articles by Yavuz, S. Related Collections Related Article