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.