Tricuspid Valve Repair—Indications and Techniques:
Suture Annuloplasty and Band Annuloplasty
Antonio Maria Calafiore, MD,* and Michele Di Mauro, MD*,†
R ecently there has been new interest in the tricuspid valve,
as different research identified late tricuspid regurgita-
tion, often a consequence of uncorrected lesion during sur-
gery, as a determinant of poor clinical outcome and even of
higher late mortality.1,2
However, it is still not clear when, at the first operation, func-
tional tricuspid regurgitation has to be corrected. In most of the
surgical articles, the decision to perform tricuspid valve (TV)
repair during mitral valve (MV) surgery was left to the surgeon’s
discretion or even was not specified.2-5 The 2008 American
Heart Association/American College of Cardiology guidelines6
suggested to perform TV annuloplasty in patients with severe
tricuspid regurgitation (TR) requiring MV surgery for MV dis-
ease (class IB); TV annuloplasty for TR less than severe should be
indicated in patients undergoing MV surgery having pulmonary
hypertension or tricuspid annular dilation (class IIB). The Euro-
pean Society of Cardiology (ESC) guidelines7 suggested to per-
form TV annuloplasty in severe TR undergoing left-sided valve
surgery (class IC) and in moderate TR with dilated annulus
(maximum systolic tricuspid annulus, TA, ⬎40 mm, 4-cham-
ber view) in patients undergoing left-sided valve surgery (class
IIA, level C).
A different surgical vision was presented by Dreyfus and
coworkers,8 who suggested performing tricuspid annulo-
plasty regardless of the grade of trisupid regurgitation, when
the tricuspid annular diameter was greater than twice the
normal size (⬎70 mm). The measurement of TA diameter
(distance between the anteroseptal commissure and the an-
teroposterior commissure) was performed in the operative
field, when the right atrium was vertically opened, using a
simple ruler. Our group9 based the decision to perform TV
annuloplasty on the preoperative echocardiographic TA sys-
tolic dimensions, as TR happens in systole. We found in a
cohort of 20 volunteers a median systolic TA value of 24 mm
with a maximum of 28 mm; thus, we decided to perform TV
annuloplasty in all cases of moderate-to-more TR and in the
case of mild functional TR when systolic TA was higher than
24 mm. The results of our study demonstrated that patients
*Department of Adult Cardiac Surgery, Prince Sultan Cardiac Center, Ri-
yadh, Saudi Arabia.
†Institute of Cardiology, University of L’Aquila, L’Aquila, Italy.
Address reprint requests to: Antonio Maria Calafiore, MD, Department of
Adult Cardiac Surgery, Prince Sultan Cardiac Center, Riyadh, Kingdom
of Saudi Arabia. E-mail: am.calafiore@gmail.com
86 1522-2942/$-see front matter © 2011 Elsevier Inc. All rights reserved.
doi:10.1053/j.optechstcvs.2011.06.002
with systolic TA ⱕ24 mm, who did not undergo TV annulo-
plasty besides MV surgery, did not show any increase of TR
grade, at least in the mid term, whereas most of the untreated
patients who showed moderate TR grade or more in the
follow-up had preoperative systolic TA within the range of 25
to 28 mm. The rate of untreated patients having preoperative
mild TR and systolic TA ⬎24 mm, whose TR was impaired to
moderate or more at follow-up, was 10%.
However, the tricuspid valve is not only annulus, but also
leaflets, chords, and papillary muscles, the position of which
depends on the right ventricle size and function. Today, sur-
gical strategies are directed mainly to the annulus or to the
annulus and the leaflets, as in the Kay technique.10 Other
techniques, addressed to the leaflets, can be interesting in
selected cases, as the edge-to-edge technique (associated with
a rigid incomplete ring or a flexible band)11 or leaflet aug-
mentation.12 These techniques, not yet standardized, are
used mainly when there is excess chordal tethering, with
increased coaptation depth of the tricuspid valve (the dis-
tance between the annular plane and the point where the
leaflets coapt). This latter concept, not yet well investigated,
was introduced by Fukuda and coworkers,4 who considered
a cut point for increased early failure rate of the annuloplasty,
6.8 mm, for late failure 5 mm, lower than the 10 mm iden-
tified for the mitral valve. Interestingly, these authors found a
correlation between early postoperative ejection fraction
⬍36.6% and late failure of TV repair, reinforcing the concept
that annuloplasty alone will not prevent TR return as a con-
sequence of LV failure, which will cause right ventricle (RV)
continuous remodeling. The strict relationship found in the
left system (MR return for left ventricular remodeling) was
found in the RV, where, however, causes of remodeling are
multiple, intrinsic, or extrinsic to the RV itself.
Furthermore, the association between annular size and TR is
not completely clear. In an interesting study, Sadeghi and co-
workers13 reported 27 patients with pulmonary thromboembo-
lism who had severe pulmonary hypertension and severe TR.
They underwent surgery without TV annuloplasty. In 19 pa-
tients (70%), the pulmonary pressure dropped by a mean of 49
mm Hg and TR was reduced to mild. In the remaining 30% of
patients, TR remained severe; pulmonary pressure reduced to
32 mm Hg, less than in the other group. Interestingly, in both
groups the annular size remained nearly unchanged (4-mm re-
duction between pre- and postoperative echocardiograms) and
similar (41 mm in the first group and 42 mm in the second
Tricuspid valve repair techniques 87

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.

group in the postoperative assessment). We can deduce that,
even if the annulus remains dilated, this does not prevent TR
reduction, but the mechanisms related to RV reverse remodel-
ing, following pulmonary artery pressure (PAP) reduction of
different degrees, are more important than the pure annular size.
Oppositely, the impact of pulmonary hypertension on se-
verity of TR, a concept that can be easily inferred by the
previous study, is not always clear. In a recent echocardio-
graphic evaluation of 2139 subjects with pulmonary hyper-
tension, Mutlak and coworkers14 found that TR was only
mild in almost 65% of subjects with PAPs 51 to 69 mm Hg
and 46% of those with PAPs ⬎70 mm Hg. Other factors, and
among them RV remodeling was one of the most important,
were at the basis of the onset of more severe grade of TR.
Unfortunately, as the mechanism of functional TR does not
dwell only in the annulus, the surgical techniques usually ap-
plied, mainly directed to annular reduction, have fluctuating
results. The RV geometry seems to be predominant in the out-
come of early and late results after TV repair, but its modifica-
tions are often unpredictable, as its positive remodeling depends
on multiple factors not always related to the surgical technique
applied. As no technique in use today addresses the RV geome-
try, we are aware that the results of TV repair are not constant
and are by far less predictable of the results of MV repair.
Tricuspid valve annuloplasty can be performed using a
suture, a strip of autologus pericardium, by means of an
incomplete ring implantation, rigid or flexible (band), 3D
shaped or planar. The procedure described by De Vega in
197215 consists of a double-layer suture annuloplasty starting
twice from the anteroseptal commissure and ending twice at
the level of the posteroseptal commissure. The final orifice
was gauged by means of 2 fingers. The surgical technique for
incomplete ring or band is roughly the same. The interrupted
sutures start at the level of the anteroseptal commissure and
end at the level of the posteroseptal commissure or at differ-
ent levels of the septal annulus.
The conundrum of annular reduction for functional TR is
how much the annulus has to be tightened. We prefer to
remodel the annulus over a no. 25 sizer, which provides a
circumference of 78.5 mm,16 but this value is largely at the
surgeon’s discretion. When a band annuloplasty is used, the
same concept is followed.17 The constant length of the band
is 50 mm; as the sutures stop at the level of the coronary
sinus, what remains is the short distance between the points
A and B (Fig. 1), roughly 30 mm.
We herein describe the 2 surgical techniques of tricuspid
annuloplasty, which we constantly use in our experience.
88 A.M. Calafiore and M. Di Mauro

Operative Technique

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.
Tricuspid valve repair techniques 89

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.
90 A.M. Calafiore and M. Di Mauro

Figure 4 Both needles of the same suture are passed into a pledget.
Tricuspid valve repair techniques 91

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.
92 A.M. Calafiore and M. Di Mauro

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).
Tricuspid valve repair techniques 93

Figure 7 Flexible band annuloplasty. The interrupted sutures (2-0 Ti-cron) start at the same point as in Fig. 2.
94 A.M. Calafiore and M. Di Mauro

Figure 8 The sutures end in front of the origin of the coronary sinus.
Tricuspid valve repair techniques
Figure 9 A 50-mm band (SMB50; Sorin, Saluggia, Italy) is positioned, to reduce the tricuspid orifice to the circumfer-
ence 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).
Conclusions
How to repair functional tricuspid regurgitation is still a
work in progress. Techniques at our disposal are mainly
addressed to the annulus, and De Vega suture annulo-
plasty and band annuloplasty are the most used. The de-
cision to perform a De Vega procedure or a ring– band
implantation is more often related to the single surgeon’s
choice. We reported an echocardiography-based decision-
making to establish whether De Vega is indicated or not. In
the case of a moderate-or-more functional tricuspid regur-
gitation (FTR) grade with systolic TA up to 28 mm, De
Vega was indicated, whereas the band was implanted for
systolic TA dimensions higher than 28 mm. In the case of
mild FTR, De Vega was performed with systolic TA 25 to
28 mm and the band was implanted when systolic TA was
higher than 28 mm.9
95
Nowadays, there is more sensibility toward the correction
of TR, at least moderate in grade, even if, sometimes, any
grade of TR is corrected. Our group demonstrated that, in
patients with functional MR, untreated less-than-moderate
functional TR provided better 5-year survival and survival in
New York Heart Association class I-II than untreated moder-
ate-or-more functional TR.1 Contrarily, comparing patients
with functional MR and moderate-or-more functional TR,
treatment of FTR with De Vega suture annuloplasty limited
the incidence, at follow-up, of residual FTR 3/4 or 4/4 and
provided better survival and survival in New York Heart As-
sociation class I-II.2
Results from TV annuloplasty are still not perfect, as the
ventricular component is, today, not addressed by the tech-
niques commonly used.18 As persistent RV dilation means
increased tethering on the TV leaflets, TV annuloplasty fail-
ure can be related to lack of RV volume regression or pro-
96
gressive RV failure due to TV-related causes or lack of regres-
sion of pulmonary hypertension.
Nevertheless, in most cases suture or band annuloplasty is
enough to assure good mid-term clinical and anatomical re-
sults.
References
1. Di Mauro M, Bivona A, Iacò AL, et al: Mitral valve surgery for functional
mitral regurgitation: prognostic role of tricuspid regurgitation. Eur
J Cardiothorac Surg 35:635-640, 2009
2. Calafiore AM, Gallina S, Iacò AL, et al: Mitral valve surgery for func-
tional mitral regurgitation: Should moderate-or-more tricuspid regur-
gitation be treated? A propensity score analysis. Ann Thorac Surg 87:
698-703, 2009
3. McCarthy PM, Bhudia SK, Rajeswaran J, et al: Tricuspid valve repair:
Durability and risk factors for failure. J Thorac Cardiovasc Surg 127:
674-685, 2004
4. Fukuda S, Gillinov AM, McCarthy PM, et al: Determinants of recurrent
or residual functional tricuspid regurgitation after tricuspid annulo-
plasty. Circulation 114:I582-I587, 2006
5. Ghanta RK, Chen R, Narayanasamy N, et al: 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 133:117-126, 2007
6. Nishimura RA, Carabello BA, Faxon DP, et al: 2008 focused update
incorporated into the ACC/AHA 2006 guidelines for the management
of patients with valvular heart disease. JACC 52:e1-e142, 2008
7. Vahanian A, Baumgartner H, Bax J, et al: Guidelines on the manage-
ment of valvular heart disease. The Task Force on the Management of
A.M. Calafiore and M. Di Mauro
Valvular Heart Disease of the European Society of Cardiology. Eur
Heart J 28:230-268, 2007
8. Dreyfus GD, Corbi PJ, Chan KM, et al: Secondary tricuspid regurgita-
tion or dilatation: Which should be the criteria for surgical repair? Ann
Thorac Surg 79:127-132, 2005
9. Calafiore AM, Iacò AL, Bivona A, et al: Echocardiographically based
treatment of functional tricuspid regurgitation. J Thorac Cardiovasc
Surg 2011 (in press)
10. Kay JH, Maselli-Campagna G, Tsuji HK. Surgical treatment of tricuspid
insufficiency. Ann Surg 162:53-58, 1965
11. De Bonis M, Lapenna E, La Canna G, et al: A novel technique for
correction of severe tricuspid valve regurgitation due to complex le-
sions. Eur J CardioThoracic Surg 25:760-765, 2004
12. Dreyfus GD, Raja SG, Chan KMJ: Tricuspid leaflet augmentation to
address severe tethering in functional tricuspid regurgitation. Eur
J Cardiothorac Surg 34:908-910, 2008
13. Sadeghi HM, Kimura BJ, Raisinghani A, et al: Does lowering pulmonary
arterial pressure eliminate severe functional tricuspid regurgitation?
Insights from pulmonary thromboendarterectomy. JACC 44:126-132,
2004
14. Mutlak D, Aronson D, Lessik J, et al: Functional tricuspid regurgitation
in patients with pulmonary hypertension: Is pulmonary artery pressure
the only determinant of regurgitation severity? Chest 135:115-121,
2009
15. De Vega NG: La anuloplastia selective regulable y permanente. Rev Esp
Cardiol 25:555-556, 1972
16. Frater R: Tricuspid insufficiency. J Thorac Cardiovasc Surg 125:9-11,
2003
17. Calafiore AM, Iacò AL, Contini M, et al: A single size band, 50 mm long,
for tricuspid annuloplasty. Eur J Cardiothorsc Surg 34:677-679, 2008
18. Navia JL, Novicki ER, Blackstone E, et al: Surgical management of
secondary tricuspid valve regurgitation: annulus, commissure, or leaf-
let procedure? J Thorac Cardiovasc Surg 139:1473-1482, 2010