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Letters to the Editor

Anterior leaflet augmentation to address tethering-induced functional tricuspid regurgitation

Division of Cardiovascular Surgery, Geneva University Hospitals, Geneva, Switzerland

Received 23 September 2008; accepted 24 October 2008.

^_* Corresponding author. Address: Division of Cardiovascular Surgery, Geneva University Hospitals, 24, rue Micheli-du-Crest, 1211 Geneva 14, Switzerland. Tel.: +41 22 372 7624; fax: +41 22 372 7634. (Email: patrick.myers{at}hcuge.ch).

Key Words: Tricuspid valve repair • Annuloplasty • Tethering • Functional tricuspid regurgitation

We read with great interest the article by Dreyfus et al. on tricuspid leaflet augmentation in functional tricuspid regurgitation [1]. We congratulate the authors for their innovative approach to relieve tethering-induced functional tricuspid regurgitation and their excellent results. As mentioned by the authors, inadequate tricuspid leaflet coaptation has been shown to arise from annulus dilatation greater than 40 mm and tethering of the valve leaflets in functional tricuspid regurgitation. Annuloplasty addresses annular dilatation, however it has not been shown to improve leaflet tethering. Several authors have proposed valve repair techniques to address severe tethering, such as a tricuspid version of the Alfieri repair or ‘clover’ technique [2] or right ventricular remodeling [3]. The method described by Dreyfus et al. is innovative, in that it is the first to increase leaflet mobility and coaptation in the dilated right ventricle. However, paraphrasing the author's own remarks on functional mitral regurgitation repair at the 22nd EACTS meeting, this remains a valvular approach to a ventricular problem. Furthermore, Park et al. recently showed in a real-time 3D echocardiographic study of 54 patients with functional tricuspid regurgitation [4] that tethering was predominantly due to the septal leaflet, and not the anterior leaflet. These results are counter-intuitive, as right ventricular free wall dilatation would appear to be a more logical explanation for tethering, resulting in predominantly anterior leaflet tethering.

Anterior leaflet augmentation should increase leaflet coaptation and decrease tethering height and tenting volume. However, given the new data provided by Park et al., this repair will significantly displace the coaptation plane closer to the septum, with a possible risk of dynamic RVOT obstruction, and it will not restore a completely physiological function to the tricuspid valve. The risk of lesions to the atrioventricular node precludes septal leaflet enlargement similar to the technique described. The fate of untreated autologous pericardium in the long-term should be assessed, as deterioration could lead to decreased anterior leaflet mobility and repair failure. Another possible strategy to treat tethering would be to suspend the septal leaflet free edge to the native anterior annulus or anterior annuloplasty ring, as we have reported in posterior leaflet retraction of the mitral valve [5] and as we have used successfully in two patients with tricuspid septal leaflet tethering in Ebstein's anomaly.

We congratulate the authors on their innovative and thoughtful approach to a complex problem. Further research into the mechanisms of functional tricuspid regurgitation is warranted and surgical strategies to treat them should be adapted. We humbly suggest, given the latest echocardiographic data on the mechanisms of tricuspid tethering, that perhaps septal leaflet augmentation would provide a more physiological solution, although it does not appear realistically feasible. Anterior leaflet augmentation should be considered a reasonable alternative, keeping in mind the alterations to the function of the tricuspid valve.

References

1. Dreyfus GD, Raja SG, John Chan KM. Tricuspid leaflet augmentation to address severe tethering in functional tricuspid regurgitation. Eur J Cardiothorac Surg 2008;34(4):908-910.[Abstract/Free Full Text]
2. De Bonis M, Lapenna E, La Canna G, Grimaldi A, Maisano F, Torracca 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(5):760-765.[Abstract/Free Full Text]
3. Kappert U, Tugtekin SM, Ouda A, Alexiou K, Schmeisser A, Schoen S, Matschke K. Right ventricular reduction as an adjunct procedure in tricuspid valve repair. Ann Thorac Surg 2008;85(5):e27-e29.[Abstract/Free Full Text]
4. Park YH, Song JM, Lee EY, Kim YJ, Kang DH, Song JK. Geometric and hemodynamic determinants of functional tricuspid regurgitation: a real-time three-dimensional echocardiography study. Int J Cardiol 2008;124(2):160-165.[CrossRef][Medline]
5. Sierra J, Lahlaidi NH, Christenson JT, Kalangos A. Mitral valve insufficiency: suspension of the posterior leaflet to the mitral annuloplasty ring. Ann Thorac Surg 2008;85(2):e6-e8.[Abstract/Free Full Text]

This article has been cited by other articles:

				S. G. Raja and G. D. Dreyfus Reply to Myers et al. Eur. J. Cardiothorac. Surg., January 1, 2009; 35(1): 195 - 196. [Full Text] [PDF]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Patrick O. Myers Aristotelis Panos Mustafa Cikirikcioglu Afksendiyos Kalangos Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Myers, P. O. Articles by Kalangos, A. Search for Related Content PubMed Articles by Myers, P. O. Articles by Kalangos, A. Related Collections Valve disease