New ring annuloplasty for extremely dilated tricuspid valve annulus: plication to physiologic septal segment size and over-reduction of posterior segment.

We describe a tricuspid valve ring annuloplasty for a 67-year-old woman who had an extremely dilated tricuspid valve annulus. During surgery, we found that the septal segment of the annulus was dilated to 60 mm, nearly double its normal size. Therefore, a standard annuloplasty without a prosthetic ring seemed unlikely to provide the needed annular plication. We used a 28-mm prosthetic ring, about the size of a normal septal segment, to plicate it. First, 5 U-shaped sutures, with 1 at each septal commissure, were used to plicate the septal segment to its physiologic size. Next, U-shaped sutures for the posterior and anterior segments were used to reduce the length of the posterior segment much more than that of the anterior segment. The septal sutures were then passed equidistantly between 2 markers on the prosthetic ring, and the remaining sutures were passed equidistantly through the ring. Finally, the prosthetic ring was affixed to the tricuspid annulus. Echocardiography revealed trivial tricuspid valve regurgitation postoperatively. In cases of dilated tricuspid valve annulus, particularly when the septal segment is very dilated, some modification of the annuloplasty may be needed. The physiologic size of the septal segment of the tricuspid valve annulus and the relative physiologic proportions of the anterior and posterior segments should be taken into consideration.