Surgical technique
In all patients, cardiopulmonary bypass was established by ascending aortic cannulation and bicaval venous drainage through a median sternotomy. TV repair was performed concomitantly with aortic valve replacement or a mitral valve procedure in all cases. After the aortic or mitral valve procedure, we performed TV repair under cardiac arrest. The number of leaflets was determined according to the definition established by Silver et al. (17): The commissure is defined as an indentation of the leaflets by fan-shaped chordae, the fan-shaped chordae forming the anteroposterior commissure arise from the anterior papillary muscle, and the posteroseptal commissure is defined by the fan-shaped chordae, which arise from the most medially placed papillary muscle on the posterior wall (10,17) (Fig. 2).
All patients underwent tricuspid ring annuloplasty using either 2-0 polyester interrupted sutures for the Carpentier-Edwards Physio Tricuspid Annuloplasty Ring or 2-0 polyester running sutures for the Tailor Flexible Annuloplasty Ring. To prevent atrioventricular node injury, we avoided placing sutures around the septal leaflet’s annulus near the atrioventricular node when using the Tailor Flexible Annuloplasty Ring (Fig. 3). The Carpentier-Edwards Physio Tricuspid Annuloplasty Ring or the Tailor Flexible Annuloplasty Ring was used according to the surgeon’s preference. The ring size was determined comprehensively by measuring the area of the anterior leaflet or annular distance of the septal leaflet using the sizers for each ring.
Upon completion of the ring annuloplasty, we checked for residual TR using the saline test. During the saline test, a surgeon compressed the pulmonary artery by hand from the outside to fill the right ventricle sufficiently. Results of the saline test was classed as follows; (a) good shape (The height of all TV leaflets was aligned. All leaflets had adequate tension and coaptation.) with no leakage (Fig. 3), (b) good shape with leakage, and (c) poor shape (The height of some TV leaflets was different and tension of leaflets was insufficient.) with leakage (Fig.4). We judged (c) as residual TR. If residual TR between the leaflets was found, we performed additional techniques to approximate leaflet edges (edge-to-edge repair). (Video)
After weaning from cardiopulmonary bypass, TR was checked by intraoperative transesophageal echocardiography.