Papillary muscle septalization for functional tricuspid regurgitation: Proof of concept and preliminary clinical experience

Figures

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  The PMs approximation to the septum realign the subvalvular apparatus in one plane.

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  Figure 1. A-D, The rationale of the PM septalization. A and B, APM-S treat the tenting by reducing the diameter AB because it allows to bring the tip of the APM closer to the annular plane and to the septum. C and D, APM-S promotes remodeling of the RV by reducing longitudinal and transverse diameters.

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  Video 1. The pathophysiology of tricuspid regurgitation implies annular dilation, right ventricular dilatation with papillary muscle dislocation, and consequent leaflet tethering. Tricuspid septalization provides a mean to correct these geometrical abnormalities via approximating the papillary muscle to the interventricular septum. The intraoperative sequence entails the use of Gore-Tex CV-4 sutures reinforced with pledgets passed through the base of the anterior papillary muscle in proximity of its insertion on the free wall which are anchored into the septum. A routine annuloplasty to stabilize the repair is then performed. Video available at: https://www.jtcvs.org/article/S2666-2507(21)00657-X/fulltext.

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  Figure 2. A-F, Combined PMs approximation to the septum with TVA. A and B, APM-S using 2 Gore-Tex 4/0 points reinforced with pledget are passed through the base of the PM near its free insertion into the wall. C and D, The APM is brought to the septum and the sutures deeply anchored to the septum, firmly attached, and tied. E, PPM-S is required to treat the tenting of septal leaflet due to PPM displacement. F, PMs-S result shows good coaptation and no more leak.

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  Figure 3. Summary of the effect of septalization plus annuloplasty in reversing the mechanism of severe FTR (Table 1, case 1). A, Anatomical changes related to TVR (yellow arrow) involve tricuspid annulus, leaflet, and subvalvular apparatus. Annular dilatation is associated to leaflet tethering (green arrow) due to PMs displacement (blue arrow). B, TVA + APM-S (approximation of APM to the interventricular septum) corrects leaflet tethering (green arrow), displacement of PMs (blue arrow), and RV remodeling (red arrow), eliminating leaflet tenting (purple arrow). C, Preoperative color flow transthoracic echocardiogram, apical 4-chamber view showing significant tricuspid regurgitation with a large central jet. D, Postoperative transthoracic echocardiogram showing a trivial tricuspid regurgitation. RV, Right ventricular; RA, right atrium.

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  Figure E1. Selection criteria to the use of combined PMs-S and TVA in patients with severe TVR. The main selection criterion is severe dilation of the tricuspid annulus with or without LHD. The benefit of the combined approach using PMs-S and TVA is suggested in patients with or without LHD. Patients with pulmonary hypertension and patients with idiopathic atrial fibrillation can greatly benefit from the procedure with improvement of TV dilation and TVR. PHTN-FTR, Pulmonary hypertension-functional tricuspid regurgitation; Id-FTR, idiopathic functional tricuspid regurgitation; RV, right ventricle; RA, right atrium.