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• W3084742364 abstract "Central MessageA new study examines the basis of functional tricuspid regurgitation and evaluates 2 annular-based repairs using an ex vivo simulator.See Article page 76. A new study examines the basis of functional tricuspid regurgitation and evaluates 2 annular-based repairs using an ex vivo simulator. See Article page 76. The survival disadvantage of uncorrected functional tricuspid regurgitation (TR) has led to more aggressive surgical treatment of TR at the time of left-sided valvular surgery. No longer a forgotten valve, current American College of Cardiology/American Heart Association guidelines recommend concomitant correction of TR based on regurgitation grade, annular dimension, and signs of right heart failure.1Nishimura R.A. Otto C.M. Bonow R.O. Carabello B.A. Erwin E.P. Guyton R.A. et al.2014 AHA/ACC guideline for the management of patients with valvular heart disease: executive summary.Circulation. 2014; 129: 2440-2492Crossref PubMed Scopus (1124) Google Scholar Most repair techniques for functional TR focus on annular remodeling, which is often sufficient to achieve a good result. In their series of 790 patients undergoing tricuspid annuloplasty with 4 different techniques, McCarthy and colleagues2McCarthy P.M. Bhudia S.K. Rajeswaran J. Hoercher K.J. Lytle B.W. Cosgrove D.M. et al.Tricuspid valve repair: durability and risk factors for failure.J Thorac Cardiovasc Surg. 2004; 127: 674-685Abstract Full Text Full Text PDF PubMed Scopus (568) Google Scholar in Cleveland reported a 15% prevalence of 3-4+ TR within 1 month of surgery. This high rate of early technical failure was similar across repair techniques, which included semi-rigid ring, flexible band, De Vega suture annuloplasty, and bovine pericardial annuloplasty. Over time, the prevalence of 3-4+ TR remained stable in the semi-rigid annuloplasty group; however, it rose rapidly in the suture annuloplasty and bovine pericardial annuloplasty group. A later study by Filsoufi and colleagues3Filsoufi F. Salzberg S.P. Coutu M. Adams D.H. A three-dimensional ring annuloplasty for the treatment of tricuspid regurgitation.Ann Thorac Surg. 2006; 81: 2273-2278Abstract Full Text Full Text PDF PubMed Scopus (83) Google Scholar found that better early outcomes could be achieved using a semi-rigid remodeling ring and more aggressive annular down-sizing. In this issue of the Journal, Amedi and colleagues4Amedi A. Ohohara D. Xu D. Suresh K.S. Padala M. Hemodynamic outcomes after undersizing ring annuloplasty and focal suture annuloplasty for surgical repair of functional tricuspid regurgitation.J Thorac Cardiovasc Surg. 2022; 164: 76-87.e1Abstract Full Text Full Text PDF Scopus (3) Google Scholar take us back from the bedside to the bench and put several repair techniques for functional TR to the test. By increasing right ventricular afterload, functional TR is generated in an ex vivo model consisting of a porcine heart connected to a pulsatile flow loop. Two repair techniques are compared; remodeling annuloplasty with the Edwards MC3 ring and focal suture annuloplasty (a technique that creates a double orifice valve by approximating the midpoint of the anterior annulus with the contralateral septal annulus5Hetzer R. The double orifice valve technique to treat tricuspid valve incompetence.J Cardiothorac Surg. 2013; 8: O103Crossref PubMed Google Scholar). Using the simulator, they measure changes in regurgitant fraction, annular dimension, tenting area, coaptation length, and leaflet excursion area. Interestingly, they find that neither technique is enough to eliminate the functional TR induced by pressure overload, likely due to leaflet tethering. This experimental finding validates what had been shown clinically by the Cleveland Clinic group: leaflet tethering is an important predictor of residual TR after tricuspid valve annuloplasty.6Fukuda S. Song J.M. Gillinov A.M. McCarthy P.M. Daimon M. Kongsaerepong V. et al.Tricuspid valve tethering predicts residual tricuspid regurgitation after tricuspid annuloplasty.Circulation. 2005; 111: 975-979Crossref PubMed Scopus (257) Google Scholar The authors' experimental findings lend support to the premise that an annular solution may not be enough to correct the geometric deformities that result in functional TR. They suggest that subvalvular repairs may also be needed. De Bonis and colleagues7De Bonis M. Lapenna E. Di Sanzo S. Del Forno B. Pappalardo F. Castiglioni A. et al.Long-term results (up to 14 years of the clover technique for the treatment of complex tricuspid valve regurgitation.Eur J Cardiothorac Surg. 2017; 52: 125-130Crossref PubMed Scopus (14) Google Scholar have taken a different approach, extending their edge-to-edge approach to the tricuspid valve with the “clover technique,” creating a triple orifice tricuspid valve. Their clinical experience using the “clover technique” as an adjunct to annuloplasty for complex TR has been good, with only 1.2% incidence of 3-4+ TR at 12-years' follow-up in a series of 96 patients. In Amedi and colleagues' model,4Amedi A. Ohohara D. Xu D. Suresh K.S. Padala M. Hemodynamic outcomes after undersizing ring annuloplasty and focal suture annuloplasty for surgical repair of functional tricuspid regurgitation.J Thorac Cardiovasc Surg. 2022; 164: 76-87.e1Abstract Full Text Full Text PDF Scopus (3) Google Scholar the degree of failure of the repair techniques (particularly the well-established semi-rigid remodeling technique) seems greater than expected based on published clinical experience. It is unclear whether this relates to specific limitations of the simulator, the degree of annular remodeling, or challenges in correlating in vivo measurements to experimental ones ex vivo. Regardless, the model may be a useful tool for developing novel adjunctive repair techniques that focus on the subvalvular apparatus. Hemodynamic outcomes after undersizing ring annuloplasty and focal suture annuloplasty for surgical repair of functional tricuspid regurgitationThe Journal of Thoracic and Cardiovascular SurgeryVol. 164Issue 1PreviewSurgical annuloplasty for functional tricuspid regurgitation (FTR) is on the rise and can be performed in several ways with varied outcomes. In this study, we sought to compare the hemodynamic outcomes of tricuspid annuloplasty performed with a commercially available annuloplasty ring (tricuspid valve annuloplasty [TVA]) compared with focal suture annuloplasty (Hetzer) in an experimental FTR model. Full-Text PDF" @default.
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• W3084742364 date "2022-07-01" @default.
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• W3084742364 title "Commentary: The shortfall of annular repair for functional tricuspid regurgitation" @default.
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• W3084742364 doi "https://doi.org/10.1016/j.jtcvs.2020.09.022" @default.
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