DeVega Annuloplasty of the Tricuspid Valve
Manuel J Antunes MD, PhD, DSC
he incidence of tricuspid regurgitation (TR) associ-
T ated with left-sided valve disease, especially nfitral,
has been described as 8% to 30%. In approximately 80%
of the cases, the TR is said to be "functional," caused by
isolated dilation of the annulus, secondary to right ven-
tricular dysfunction, and in the remainder, the lesion is
primarily rheumatic (organic), usually with fibrosis of the
leaflets and fusion of the conunissures2 Managemet~t of
TR during surgery of the mitral and aortic valves is
becoming increasingly important.
FUNCTIONAL VERSUS ORGANIC
TRICUSPID REGURGITATION
In 1967, Braunwald and colleagues 2 wrote that "in
"most" patients with secondary TR, the surgical treat-
ment of mitral valve disease corrects the right sided
problems." It should be expected that by eliminating
the triggering factor, after adequate correction of left
heart valve disease, the tricuspid regurgitation would
regress, but this does not always happen. F u r t h e r m o r e ,
the results of mitral valve surgery are less favorable in
patients with associated right heart disease.
Hence, the quality of the correction of the left-sided
valvulopathy appears fundamental. Any incomplete or
unsatisfactory repair will result in persistence or pro-
gression of the TR. Even with long-term success of
mitral valve surgery, in many cases, there is a progres-
sive increase of tricuspid regurgitation, which may give
reason to question its "functional" etiology. Barlow and
colleagues have postulated that tricuspid regurgitation
is often partly or mainly organic. 3
Recent evidence demonstrates that functional
TR can be ignored only in patients with predictable
and significant reduction in pulmonary resistance,
which usually follows early correction of left-side pa-
thology. Then when should we repair/replace the tri-
cuspid valve during left-sided valve surgery?
The evaluation and treatment of the secondary TR
continues to be a major problem in the surgical deci-
sion-making process. There is no reliable method to
judge how much of it is reversible when left-sided prob-
lems are corrected. Additionally, there is a lack of
reliable methods for quantifying the degree of tricuspid
regurgitation, and for assessing true right ventricular
function. On the other hand, Dreyfus and coworkers 4
found, very recently, that "secondary" tricuspid annu-
lar dilation is present in a significant n u m b e r of pa-
Operative Techniques ill Thoracic and Cardiovascular Surgery, Vol 8, No 4 (November), 2 0 0 3 : pp 169-176
tients with severe mitral disease without TR, which
does not resolve with correction of the p r i m a r y lesion
alone. They conclude that in these patients, "tricuspid
annuloplasty at the time of mitral valve surgery results
in improved functional capacity without any increase in
perioperative morbidity or mortality."
ASSESSMENT OF TRICUSPID VALVE
REGURGITATION
On examination, severe TR is usually associated with a
fixed raised jugular venous pressure (JVP), a palpable
pulsatile liver and, frequently, peripheral edema. The
assessment of the severity of tricuspid valve regurgitation
is made by echocardiography and by Doppler identifica-
tion of the regurgitant jet, and indirectly by detection of
hepatic portal venous flow and of right ventricular dila-
tion. During surgery, dilated right atrium and ventricle is
an indirect sign of severe TR, especially in the absence of
severe pulmonary hypertension.
In the final instance, the indications for surgery of
tricuspid regurgitation in association with mitral valve
disease include obviously severe TR preoperatively and
worse than expected TR detected intraoperatively. But
two major problems remain: what to do with lesser
degrees of TR; and how to predict those patients who
will r e t u r n after mitral valve surgery with persistent,
bothersome tricuspid regurgitation?
VALVE REPLACEMENT VERSUS
REPAIR
The major remaining controversies in tricuspid valve
surgery are the choice between repair and replacement,
the effectiveness of different methods of repair, and,
when replacement is required, the type of prosthesis.
Only exceptionally will the tricuspid valve need to be
replaced as a first procedure, because the valve toler-
ates well a less-than-perfect repair. Besides, prosthetic
tricuspid valve replacement is associated with high
rates of mortality and morbidity. Hence, annuloplasty
is the surgery of choice and may be achieved with
sutures or rings. We believe that implantation of a ring
is specifically indicated when there is organic involve-
ment of the tricuspid valve, usually with stenosis,
where commissurotomy is also necessary. In "func-
tional" TR, a suture annuloplasty has yielded excellent
results in most surgeons' experience.
Among several types of suture annuloplasty in use,
the technique originally described by Dr. Norberto
169
170 ANTUNES

DeVega, 5 o r one of its m a n y modifications, is the most t e r i o r leaflets. S e v e r a l modifications of the original
c o m m o n l y p e r f o r m e d . It aims at r e d u c i n g a n d fixing the t e c h n i q u e h a v e b e e n d e s c r i b e d , which were designed to
size of the a n n u l u s in the segments t h a t a r e p r o n e to d e c r e a s e the i n c i d e n c e of s u t u r e - r e l a t e d tissue t e a r i n g ,
dilation, those c o r r e s p o n d i n g to the a n t e r i o r a n d pos- e v e n t u a l l y resulting in a bow-string effect.

SURGICAL TECHNIQUE

Midline sternotomy

Alternative
access with right
thoracotomy ~

Pericardial incision

i! 'i!i

Although the right thoracotomy and other so-called nfini-invasive or less invasive sternal incisions recently have gained the interest
of many surgeons, the most commonly used approach to tile left-side heart valves is still the classic median sternotomy. After sternal
opelling, an inverted-T incision of the pericardium is made. A pericardial cradle is created with tln'ee or four sill, sutures in the edges of
the pericardium on each side, which are pulled up and secured between the sternum and the blades of the retractor.
DeVEGA ANNULOPLASTY OF THE TRICUSPID VALVE 17 1

A Purse strings placed at sites of cannulation for bypass

Aof

Superior v

2 2 ~ k After confirmation of the indirect signs of tricuspid regurgitation, such as dilated right atrium and ventricle, and
administration of heparin, purse-string sutures are placed in the right atrial appendage and in the lateral wall immediately
above the inferior vena cava, for venous drainage, and in the distal ascending aorta, for arterial return. Some surgeons prefer
to cannulate the superior vena cava directly. IVC, inferior vena cava; PV, right pulmonary veins; PA, pulmonary artery; RA,
right atrium; SVC, superior vena cava.

2]~ The arterial and venous cannulae are placed and cardiopulmonary bypass is commenced. At 28~ to 30~ the aorta
is cross-clamped and cardioplegia perfused into the aortic root. Snares previously placed around both vena cavae are
tightened, to exclude the right atrium from venous blood. Our preferred approach to the mitral valve is the classic incision
in the atrial wall, just posterior to the interatrial groove, in which case the right atrium is opened only after completion of the
mitral valve surgery. However, in cases of significant biatrial enlargement, we usually access the mitral valve through a
longitudinal incision in the interatrial septum after entering the right atrium. The right atrial incision begins next to the atrial
appendage, occasionally displacing the superior venous drain, and progresses in an oblique downward direction, to end close
to the inferior vena caval drain. Depending on the size of the atrium, it may extend beyond the crista terminalis.
172 ANTUNES

j/

~of
tvMve

3 For adequate exposure of the valve, we use a Cooley tricuspid retractor. Alternatively, appropriately placed traction
sutures may be used. The anatomy of the tricuspid valve is assessed (the position of the conduction system and of the atrial
portion of tile membranous interventricular septum should also be noted). A dilated annulus is invariably present. If the
leaflets are not involved by the pathological process, the final decision is made to proceed to a DeVega annuloplasty. In cases
where the tricuspid leaflets arc retracted and there is commissural fusion, a Carpeutier ring is preferred.
A B
3~0 Polypropylene
1st row of sutures placed
in annulus around
anterior & posterior
leaflets

C
%

Sutures being drawn

and tied

'4 The classic annuloplasty consists of a double continuous suture which runs along the anterior and posterior annulus,
corresponding to the right ventricular free walls, which are mostly involved in this process. The septal portion of the annulus
is usually not involved in the dilation process and is spared for protection of the conduction system. In the classic DeVega
technique, a 2/0 or 3/0 polypropylene suture is commenced at the posterior extremity of the septal portion of the annulus and
continues, in an anticlockwise direction, in the posterior and anterior portions of the annulus. The suture needle penetrates
at a depth of 1 to 2 mm, in bites approximately 5 to 6 mm long (A). Once the suture reaches the fibrous trigone, close to the
antero-septal commissure, it is reversed over a Teflon@ felt pledger, Each bite of the annulus in the second suture hne
intercalates that of the first one (B). The suture ends where it started and is tied over a Teflon@ felt pledget (C). The degree
of narrowing of the annulus may be controlled over a Hegar dilator or a valve sizer, between 25 mm and 29 mm, depending
on the body surface of the patient, but having in mind that mild stenosis is better tolerated than regurgitation. Though not
done routinely, the valve may be tested by injecting cold saline into the right ventricle with a bulb syringe.
174 ANTUNES

Bites & pledgets o f 2 n d row interdigitating

A with those o f the tst row

Each bite on a pledget

in fat row of~utures

0
,~ ~ ! ! ~ i ~ ! ~ i ~ 84184
~ # i~iiiiiii~iiiiiiiiiiiii~ii~/
Suture

f~

In this modified technique, described by us in 1983, 6 Teflon| felt pledgers are interposed in each bite of the suture in
the annulus. We usually start the suture in the septal annulus, about 10 mm from the postero-septal commissure. The suture
continues along the posterior and anterior annuli and ends in the central fibrous body, next to the antero-septal commissure.
Five or six pledgets are used. The suture is then reversed and another pledger is intercalated in each bite, between those in
the first row. In the end, a total of 11 to 13 pledgers will have been used. We have found that tying the knot to obtain a good
tightening of the pledgets, resulting in a C-ring-type annuloplasty, leads to a tricuspid orifice which admits two fingertips
(diameter of approximately 25-27 ram), withoL~t the need for the use of obturators to control the final size of the orifice. We
also believe that the addition of the pledgets permits a more uniform distribution of tension, thus resolving the problem of the
suture tearing of the annulus with the bow-string effect. Initially, we had used commercially available precut oval pledgets but
found tl~ese to be too small and now cut them from a patch of Teflon| felt. Each rectangular pledget measures approximately
5 mm • 4 mm and is placed lengthwise (larger dimension along the annulus). To facilitate the handling of the pledgets during
penetration by the suture needle, we have developed a special instrument that has a deep cut in the jaws through which the
needles are passed (inset).
DeVEGA ANNULOPLASTY OF THE TRICUSPID VALVE
6 Intraoperative photograph of a tricuspid valve after a modified DeVega annuloplasty performed according with the
technique described in Fig 5. The two rows of pledgets appear as one single flexible "ring" of felt. The valve was closed by
injecting saline with a bulb syringe into the right ventricle
CONCLUSION
Between M a r c h 1988 and D e c e m b e r 2002, 399 pa-
tients who h a d t r i c u s p i d regurgitation associated
with mitral valve disease (16% of the total) were
s u b j e c t e d to t r i c u s p i d valve surgery at o u r D e p a r t -
ment. The f r e q u e n c y of tricuspid annuloplasty con-
c o m i t a n t with m i t r a l valve s u r g e r y i n c r e a s e d to
2 6 . 4 % in the past 5 years. Only three patients h a d
valve replacement. The r e m a i n d e r h a d a n n u l o p l a s t y ,
26 with implantation of a ring and 370 by a modified
DeVega annuloplasty. 6 The latter was p e r f o r m e d b y
all surgeons in the D e p a r t m e n t , including senior res-
idents. The 30-day mortality was identical (1.3%) for
patients who h a d tricuspid a n n u l o p l a s t y and for
those who did not have tricuspid valve surgery. Only
two patients r e q u i r e d r e o p e r a t i o n for persistent or
r e c u r r e n c e of severe TR. No case of dehiscence of the
s u t u r e was identified.
Thus, in o u r experience, the modified DeVega tri-
cuspid a n n u l o p l a s t y p r o v e d to be a safe p r o c e d u r e
for the m a n a g e m e n t of s e c o n d a r y tricuspid regurgi-
tation. It is technically easy and r e p r o d u c i b l e even
175
by relatively i n e x p e r i e n c e d surgeons. In o u r view, it
should be used in all patients with more than mild
" f u n c t i o n a l " tricuspid regurgitation. We 7 have rec-
o m m e n d e d and followed this policy for more than a
decade with encouraging results, inasmuch as we
have o b s e r v e d a low rate of late r e o p e r a t i o n s . Recent
evidence may suggest that it should be used " p r o p h y -
lactically" even in patients with a n n u l a r dilation in
absence of significant regurgitation.
We have reserved rigid ring annuloplasty (Carpen-
tier-Edwards) for patients with organic tricuspid regur-
gitation with commissural fusion requiring commissur-
otomy, where reshaping of the valve is fundamental.
P r i m a r y valve replacement has been necessary only in
a very small n u m b e r of patients with severe destruction
of the Valve caused by infective endocarditis.
REFERENCES
1. King RM, Schaff HV, Danielson GK, et al: Surgery for tricuspid regur-
gitation late after mitral valve replacement. Circulation 70:193-199,
1984, (Snppl 1)
176 ANTUNES

2. Braunwald NS, Ross J, Morrow AG: Conservative management of tri- 7. Antunes MJ: Segmental tricuspid annuloplasty revisited (letter). J Tho-
cuspid regurgitation in patients undergoing mitral valve replacement. rac Cardiovase Surg 103:1025, 1992
Circulation 35:63-69, 1967, (suppl l)
3. Pocock WA, Antunes MJ, Sareli P, et al: Late postoperative course and
complications: emphasis on the "restrictive dilatation" syndrome, In
Barlow JB, ed: Perspectives on the Mitral Valve. Philadelphia, PA, FA
Davis, 1987, pp 270-288
4. Dreyfus G, Bahrami T, John Chan KM, et al.: Secondary tricuspid From the Department of Cardiothoracic Surgery, University Hospital, Coimbra,
dilatation with or without regurgitation: should it be repaired? Proceed- Portugal.
ings of the XIV Annual Meeting of the EACTS, Monaco, October 2002, p Address reprint requests to Manuel J Antunes, Cirurgia Cardiotorfieiea,Hospi-
206 tals da Universidade, 3000, Coimbra, Portugal.; e-mail: antunes.eet.hue@mail.
5. DeVega NG: La anuloplastia selective, reguable y pennanente. Rev Esp telepae.pt
Cardiol 25:6-9, 1972 9 2003 Elsevier Inc. All rights reserved.
6. Antunes MJ, Girdwood RW: Segmental tricuspid annuloplasty: A mod- 1522-2942/03/0804-0003530.00/0
ified technique. Ann Thorac Surg 35:676-678, 1983 doi:10.1053/S1522-9042(03)00046-3