Surgical repair of functional tricuspid regurgitation by drawing the anterior and posterior papillary muscles towards the septum, corrected regurgitation and restored physiologic valve kinematics.

Abstract

Surgical repair of functional tricuspid regurgitation (FTR) due to annular dilatation and leaflet tethering from a dilated right ventricle is increasingly performed; however, the optimal approach for such a repair is unclear. In this study, using a diseased model of FTR, we compared annular repair and subannular repair strategies to repair FTR and restore native valve kinematics and mobility. A model of FTR was developed using porcine tricuspid valves in a pulse duplicator (n = 11 hearts). The effect of TV annuloplasty (TVA) in reducing FTR was studied first, followed by subannular repair by septal relocation of the posterior and anterior papillary muscles (TVPA), and then a combination of the 2 techniques (TVA+TVPA). FTR was quantified before and after each repair, and real-time ultrasound was used to quantify leaflet coaptation, tenting, and leaflet mobility. At baseline, all valves were competent without FTR. In the FTR model, the regurgitation fraction increased to 28 ± 16.2%. With TVA, the regurgitation fraction was reduced to 11.3 ± 5.9% with a 30-mm ring and to 4.6 ± 3.8% with a 28-mm ring. With TVPA alone, the regurgitation fraction was reduced to 6.5 ± 8.5%, and when TVA+TVPA were combined, it reduced to 2.9 ± 4.3% with a 30-mm ring and to 1.3 ± 1.6% with a 28-mm ring. The largest systolic coaptation height and leaflet mobility were achieved with TVA+TVPA, with physiologic levels of leaflet mobility restored. In this diseased model, correction of FTR, restoration of highest systolic coaptation height and physiologic leaflet mobility were achieved with isolated sub-annular repair and further enhanced with concomitant annular repair.