Papillary muscle relocation and annular repositioning for functional tricuspid regurgitation

New subvalvular procedures for the treatment of TR with leaflet tethering.

Figure 1. A, Preoperative echocardiogram showing regurgitation occurring due to annular dilatation and leaflet tethering (anterior and septal leaflet tethering [tethering height 15.0 mm], annular dilatation [annular diameter 56.0 mm], and right ventricular dilatation [right ventricular diastolic diameter 56.0 mm, systolic diameter 49.2 mm]). B, Intraoperative picture showing tethering of all leaflets. RV, Right ventricle; RA, right atrium.

Figure 2. The concept of new subvalvular procedures for the treatment of TR with leaflet tethering. In anterior papillary muscle relocation, the CV-4 sutures are placed in the anterior papillary muscle. The free ends of them are passed through the corresponding anterior annulus. In annular repositioning, the CV-4 sutures are anchored to the RV septum around the origin of the papillary muscle or chords belonging to the septal leaflet. The free ends of them are passed through the corresponding septal annulus and ring. The degree of papillary muscle relocation and annular repositioning is determined based on the saline test results. During saline injection into the RV cavity with manual compression of the main pulmonary artery, the CV-4 sutures are tied when the anterior and septal leaflet approach the annular plane. By applying annular repositioning, the septal annulus relocates in the direction of the RV cavity. This maneuver leads to tilting of the annular plane with the rigid ring. As a result, the septal leaflet approaches the annular plane, and leaflet tethering is relieved. RV, Right ventricular; RA, right atrium.