eComment. Adjustable tricuspid annuloplasty for functional tricuspid regurgitation.

Functional tricuspid regurgitation (FTR) is a neglected and underestimated pathology. It occurs mostly from annular dilatation and right ventricular enlargement, which is frequent secondary to left-sided heart failure from myocardial or valvular causes, right ventricular volume and pressure overload, and dilatation of the cardiac chambers. Moderate-to-severe FTR should be corrected to improve shortand longterm outcomes in patients undergoing surgery for left-sided valvular diseases. Tricuspid annuloplasty is a safe and effective surgical option for FTR and seems to be associated with an improvement in both functional status and survival. I read with great interest the paper by Iida et al. [1]. They described a novel technique of adjustable annuloplasty for FTR employed in 11 patients. In their technique, an expanded polytetrafluoroethylene thread was passed inside the cover cloth of a flexible annuloplasty band. They tightened the thread with extracardiac control on beating heart under observation by transoesophageal echocardiography (TEE) after weaning off cardiopulmonary bypass (CPB). I would like to add a short comment on this annuloplasty technique. For the last four decades, various repair techniques have been described for the surgical correction of FTR with severe tricuspid annular dilatation. These broadly include ring annuloplasties (flexible and rigid prosthetic rings or three-dimensional rings, flexible prosthetic bands) and suture annuloplasties such as bicuspidization (Kay annuloplasty) or semicircular (De Vega annulopasty). Other approaches may include the edge-to-edge technique (Alfieri-type) or anterior tricuspid leaflet augmentation to increase leaflet coaptation and relief of tethered leaflets [2]. The selection of the appropriate repair is the most important issue in the management of FTR. Although ring annuloplasty seems to increase durability of valve repair, the De Vega annuloplasty modifications are still advocated because of their good results. To adjust the constriction of tricuspid annulus on the beating heart, after discontinuation of CPB, Alonso-Lej [3] described an adjustable modification of the De Vega annuloplasty. Herein, extracardiac control of suture annuloplasty was gained by taking both ends of the suture through the wall of the right atrium after weaning off CPB. The degree of tricuspid regurgitation now is evaluated solely with TEE rather than with digital palpation [3]. Adjustable segmental tricuspid annuloplasty is a new modified technique that tries to reduce the incidence of failure in the De Vega annuloplasty and adjusts and distributes the pursing forces in the more dilated area. Sarraj et al. [4] have used two separate sutures, and they have chosen the middle point between the anteroseptal commissure and posteroseptal commissure to perform the purse-string technique. These new modifications make the technique more selective in the remodelling of the tricuspid annulus. Choi et al. [5] described a modified technique of tricuspid ring annuloplasty to reduce postoperative residual regurgitation in patients with FTR; first, an adjustable segmental tricuspid annuloplasty is performed to obtain coaptation of the valve leaflets with two 5-0 monofilament annular sutures, and then a prosthetic ring of the same size as the competent valve area is implanted with continuous 3-0 polypropylene sutures. Finally, I think that continued follow-up should be mandatory for confirming the effectiveness of these tricuspid annuloplasty techniques.