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Ann Thorac Surg 1995;59:891-895
© 1995 The Society of Thoracic Surgeons

Partial Annular Plication for Atrioventricular Valve Regurgitation

Departments of Thoracic and Cardiovascular Surgery, Pediatrics, and Cardiology, Wonkwang University, Iri, South Korea

Accepted for publication December 10, 1994.

	Abstract

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Various annuloplasty techniques are used to correct tricuspid or mitral valve regurgitation. We performed a partial annular plication procedure, a modification of the annuloplasty introduced by Davila, in 23 consecutive patients with moderate to severe tricuspid regurgitation or moderate mitral regurgitation. A slender plastic tube was used to tighten snugly the suture during intraoperative saline flushing test for assessment of the valve competency. This technique enabled us to add one stitch or two for more plication before the suture was tied if necessary. During a mean follow-up period of 13.8 months postoperatively, 10 patients (43.5%) had no valve regurgitation, 12 patients (52.2%) had grade 1+ regurgitation, and 1 patient (4.3%) grade 2+ on color Doppler echocardiography. The regurgitation grade remained unchanged or improved after the initial postoperative study. Our surgical experience indicates that the adjustable procedure of partial annular plication is a simple, exact, and durable procedure in patients of all ages with moderate to severe functional atrioventricular regurgitation.

	Introduction

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Regurgitation of the atrioventricular (AV) valve may be present in patients with acquired or congenital cardiac disease [1–3]. In a majority of patients with tricuspid regurgitation (TR), the condition is functional in nature, secondary to pulmonary hypertension and right ventricular dilatation [4]. Opinions vary as to whether to expect spontaneous regression of functional tricuspid insufficiency after repair of the mitral lesion [5] or to perform tricuspid annuloplasty or even valve replacement [6, 7]. Tricuspid valve annuloplasty is a safe and effective surgical procedure for which there are several techniques. In the present report, we describe a simple technique of partial annular plication (PAP), a modification of the plication annuloplasty introduced by Davila [8], for patients with functional TR or mitral valve regurgitation (MR). We evaluated the efficacy of PAP by color Doppler echocardiography (CDE) in 23 consecutive patients with functional TR or MR.

	Material and Methods

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Patients
Between January 1991 and June 1994, annular plication procedure was performed in 23 consecutive patients with moderate to severe AV valve regurgitation. Of these patients, 19 patients underwent tricuspid annular plication, 3 patients mitral annular plication, and 1 patient combined mitral and tricuspid annular plication. Eight patients were less than 13 years of age (range, 1 to 13 years; mean, 7.9 years; 4 male and 4 female patients) and 15 were older than 22 years (range, 22 to 68 years; mean, 47.7 years; 3 male and 12 female patients). The 8 children had congenital heart disease (ventricular septal defect in 3 patients; univentricular heart in 2; postoperative state of tetralogy in 1; ventricular septal defect, atrial septal defect, and patent ductus arteriosus in 1; and tricuspid valve endocarditis and ventricular septal defect in 1) and the adults had rheumatic valvular heart disease in 9 patients, coronary artery disease in 3, and atrial septal defect in 3. Of the children, 6 had moderate TR and 2 had moderate MR. Of the adults, 6 patients had severe TR, 7 had moderate TR, 1 had moderate MR, and 1 had moderate MR and TR.

Preoperative diagnosis of TR was made by CDE and was confirmed by finger palpation intraoperatively, and that of MR was made by CDE and left ventriculography. Color Doppler echocardiography was performed before operation and 2 weeks and 6 months after operation to determine the severity of TR or MR. The regurgitation was graded semiquantitatively in parasternal long-axis, short-axis, and apical four-chamber view on a scale of 1+ to 4+ according to the maximum systolic distance of the regurgitant jet in relation to the atrial long-axis diameter: grade 1+ was assigned if the jet extended immediately behind the valve, grade 2+ (mild) if it extended up to one third of the length of the atrium, grade 3+ (moderate) if up to two thirds, and grade 4+ (severe) if more than two thirds into the atrium. Indications for partial annular plication of tricuspid valve were TR of grade 3+ or more as evaluated by CDE, moderate to severe TR as assessed by digital palpation through right atrial appendage before the institution of cardiopulmonary bypass, and preoperative findings of jugular venous distention or hepatomegaly. Indications for PAP of mitral valve were MR of grade 2/4 to 3/4 as determined by left ventriculography and grade 3+ or more as evaluated by CDE.

Concomitant procedures carried out at the time of PAP were mitral valve replacement in 3 patients (including 1 patient with maze procedure for chronic atrial fibrillation in addition to mitral valve replacement), combined mitral and aortic valve replacement in 6 patients (including 1 patient with maze procedure), repair of congenital defects in 10 patients (closure of ventricular septal defect in 5 patients, closure of atrial septal defect in 3, total bidirectional cavopulmonary connection in 1, and bidirectional cavopulmonary shunt in 1), coronary artery bypass grafting in 2 patients, and repair of postinfarction ventricular septal defect and coronary artery bypass grafting in 1 patient. One 6-year-old girl who had tricuspid valve endocarditis underwent en bloc excision of a vegetation from the anterior leaflet of tricuspid valve, valve repair, and partial annular plication. Two children with univentricular heart had moderate functional regurgitation of systemic AV valve preoperatively.

Pulmonary artery systolic pressure before operation was 45.0 ± 12.5 mm Hg (mean ± standard deviation) (range, 32 to 65 mm Hg) in the adult group with mitral valve lesion accompanying TR and 76.3 ± 24.9 mm Hg (range, 40 to 100 mm Hg) in children with congenital heart disease combined with AV valve regurgitation. Three adults who had atrial septal defect showed moderate to severe TR and marked dilatation of the right atrium and ventricle, but their pulmonary artery systolic pressures were less than 30 mm Hg preoperatively.

Surgical Technique
A standard median sternotomy was used for operative exposure in all patients. After full systemic heparinization was established, cardiopulmonary bypass was carried out by cannulation of ascending aorta and direct bicaval cannulation. The aorta was cross-clamped and intermittent cold crystalloid cardioplegia was used for myocardial protection. The tricuspid valve lesion was examined by right atriotomy and the mitral valve was examined and corrected through interatrial septotomy in almost all patients with mitral valve lesion. If there were no structural change on the leaflets and subvalvular structures, then adjustable partial annular plication was performed. The annuloplasty technique introduced by Davila was modified to adjust the degree of annular plication correctly before the suture was tied (Fig 1).

View larger version (19K): [in this window] [in a new window]   Fig 1. . Partial annular plication for tricuspid valve regurgitation. Three furling stitches with four pledgets or four furling stitches with five pledgets are placed in two rows. The stitch begins just posterior to coronary sinus (CS) and continues to some annular portion of anterior leaflet in counterclockwise direction (A). A snugger of plastic tube enables one to place additional stitches, if more plication is necessary, during saline flushing test (B). The suture is tied snugly (C).

In the mitral valve, the first stitch began just anterior to the commissure between the anterior and posterior leaflets and the sutures were continued posteriorly along the annulus of mural leaflet (Fig 2). Valve competence was confirmed with the same test as in the tricuspid valve.

View larger version (18K): [in this window] [in a new window]   Fig 2. . Partial annular plication for mitral valve regurgitation. Two furling stitches with three pledgets or three furling stitches with four pledgets are placed along the annulus of either or both sides. The stitch begins just anterior to the commissure between the anterior and posterior leaflets and continues downward along mural annulus. A plastic snugger also is used during competence test of the valve.

Follow-up
Patients were followed up, as outpatients, by CDE every 6 months. The mean follow-up period was 13.8 months, with a range of 6 to 39 months.

	Results

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
There was no early or late death during a mean follow-up period of 13.8 months postoperatively. The TR in all patients who underwent tricuspid annular plication was functional. The preoperative severity of TR or MR as evaluated by CDE was grade 3+ in 17 patients (73.9%) and grade 4+ in 6 patients (26.1%). There was no patient who required tricuspid valve replacement during the study period. For the follow-up period after operation, 10 patients (43.5%) had no regurgitation flow, 12 patients (52.2%) had grade 1+ TR or MR, and 1 patient (4.3%) had grade 2+ TR on CDE; no patient had TR or MR of more than grade 2+. Of 6 patients with grade 4+ TR on preoperative CDE, 2 patients had no regurgitation, 3 patients had grade 1+ TR, and 1 patient had grade 2+ TR postoperatively. In the patient who had grade 2+ TR two weeks after operation, the regurgitation improved progressively for 6 months postoperatively (Fig 3). As to the functional status of the adult patients after operation, 11 patients (73.3%) were in New York Heart Association functional class I and 4 patients (26.7%) were in class II, with a mean class improvement of 1.6. There was no conduction disorder either early or late after operation. No patient has had development of recurrent regurgitation, exacerbation of regurgitation, or tricuspid stenosis secondary to reduction of annular dimensions during this study period.

View larger version (2K): [in this window] [in a new window]   Fig 3. . Color Doppler echocardiographic evaluation of tricuspid regurgitation before and after partial annular plication. Preoperative echocardiogram showed grade 4+ tricuspid regurgitation (A). It improved to grade 2+ two weeks after operation (B), and tricuspid regurgitation was not present 6 months after operation (C). (LA = left atrium; RA = right atrium; RV = right ventricle.)

	Comment

Top Footnotes Abstract Introduction Material and Methods Results Comment References

The optimal goal of the treatment of valvular insufficiency is reconstruction instead of replacement. After modern techniques of myocardial protection came into general use, the operative mortality decreased dramatically, and operative death due to AV valve annuloplasty is rare now [11, 14, 15]. Tricuspid annuloplasty is attractive because it is a simple and short procedure, but it requires essentially intact tricuspid architecture [4].

We consider the de Vega annuloplasty [15] the simplest, most elegant, and best proven method for the repair of functional tricuspid regurgitation. The use of periannular suture, however, could result in a migration of the suture centripedally, creating a fibrous shelf over the orifice, or in a cutting through of the suture with the suture eventually lying like a chord or bowstring across the orifice. Such a failure would be more likely when this technique was used for TR with pulmonary hypertension or MR [8]. We had used this technique for tricuspid regurgitation until October 1989, but since then we have replaced the technique with a simpler and more exact technique. Davila [8] introduced a simple annuloplasty technique that can avoid the disadvantage of the de Vega annuloplasty and be used for both MR and TR. We modified Davila's procedure to get more adaptability during operation. The furling stitches into the annulus begin just posterior to the coronary sinus and continue up to the middle third of the anterior leaflet annulus in counterclockwise direction, advancing 10 mm with each pair of stitches. Two ends of the suture are tightened by a slender snugger of plastic tube without removal of the two needles of the double-armed suture, and then the competence of the valve is tested with saline solution. If necessary, one furling stitch or two can be added before the suture is tied. This plication procedure also can be applied to either side or both sides of the mitral commissure in patients with functional MR.

Some surgeons recommend ring annuloplasty for severe TR because of the high recurrence rate after the de Vega-type extensive semicircular annuloplasty and the enormous annular tension on the annuloplasty stitch [16, 17]. With Davila's plication procedure applied, the felts sandwiched in the furlings will be infiltrated by tissue and provide a solid scar, which will prevent the suture from cutting through. This technique therefore can be useful especially in children with weak annular tissue. Inserting a pledget between two furling stitches may be meaningless, but inserting pledgets among three furling stitches or more is important to avoid the cutting through of the suture and the excessive plication of the valve leaflet.

When PAP is performed at the appropriate annular portion with the simultaneous reconstruction of valve leaflets and subvalvular apparatus in patients with MR, it can be a satisfactory procedure to maintain annular strength without using a ring. In our limited experience of PAP for MR, we cannot confirm the procedure is preferred to the implantation of a ring, but it can replace ring annuloplasty in the mitral valve with intact mural annular strength.

A major concern was progressive dilatation of the intact annulus remaining after the annular plication procedure, but there was no recurrence or exacerbation of the valve regurgitation even in the patients with systemic AV valve regurgitation (ie, 2 patients with univentricular heart and AV valve regurgitation and 3 patients with moderate mitral regurgitation).

Partial annular plication of the tricuspid valve looks like the bicuspidalization annuloplasty advocated by Kay and associates [18] because the major part of plication is performed at the posterior of the valve. It does not completely exclude the posterior leaflet, however, and leaves the partially functioning posterior leaflet and annulus. This PAP may be useful especially in growing children because the partial segment of the mural annular circumference remains intact. In children with complex heart disease associated with AV valve regurgitation caused by annular dilatation, one or two separate plications are made at the annulus around each commissure without damaging the conduction system.

The PAP can be performed with three furling stitches with four pledgets in almost all patients with moderate functional TR or MR. As a plastic snugger is used to tighten the plicated annulus during competence testing of the valve before the suture is tied, one can add one furling stitch or two to get nearly complete competence. It is important to confirm no substantial leakage from the valve with proper distention of the ventricle during the intraoperative saline flushing test. When any substantial leakage from the valve remains after the annular plication procedure and one stitch or two cannot be added because of marked distortion of the plicated annulus, a second plication is made separately at the annulus of another commissure and the annular circumference can be reduced to a normal valve orifice for age and weight [9]. If there is any significant leakage from the valve even with this second plication procedure, one must consider valve replacement. There was no patient who underwent tricuspid valve replacement during this study period in our series.

In the patients who underwent PAP for MR or severe TR, we confirmed valve competence by transesophageal echocardiography on the beating heart during the temporary weaning of cardiopulmonary bypass after the procedure. When any significant incompetence remains as shown by intraoperative Doppler echocardiography, cardiopulmonary bypass must be reinstituted and the repair tried again before valve replacement.

In conclusion, the adjustable procedure of partial annular plication can be used simply and exactly for moderate to severe functional TR or for moderate MR. It has advantages over the other procedures, especially in the treatment of TR. However, further studies are needed to evaluate the wider use of PAP in the treatment of adults with severe MR.

	Footnotes

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Address reprint requests to Dr Choi, Department of Thoracic and Cardiovascular Surgery, Wonkwang University School of Medicine, 344-2 Sinyong-dong, Iri, Jeonbuk, 570-180, South Korea.

	References

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 

1. Kirklin JW, Pacifico AD. Surgery for acquired valvular heart disease. 2. N Engl J Med 1973;288:194–9.[Medline]
2. Breyer RH, McClenathan JH, Michaelis LL, McIntosh CL, Morrow AG. Tricuspid regurgitation: a comparison of nonoperative management, tricuspid annuloplasty, and tricuspid valve replacement. J Thorac Cardiovasc Surg 1976;72:867–74.[Abstract]
3. Carpentier A. Congenital malformations of the mitral valve. In: Stark J, de Leval M, eds. Surgery for congenital heart defects. Philadelphia: Saunders, 1994:599--614.
4. Chidambaram M, Abdulali SA, Ganesh Baliga B, Ionescu MI. Long-term results of DeVega tricuspid annuloplasty. Ann Thorac Surg 1987;43:185–8.[Abstract]
5. Braunwald NS, Ross J Jr, Morrow AG. Conservative management of tricuspid regurgitation in patients undergoing mitral valve replacement. Circulation 1966;35(Suppl 1):63–9.
6. Nakano S, Kawashima Y, Hirose H, et al. Evaluation of long-term results of bicuspidalization annuloplasty for functional tricuspid regurgitation. A seventeen-year experience with 133 consecutive patients. J Thorac Cardiovasc Surg 1988;95:340–5.[Abstract]
7. Cohen SR, Sell JE, McIntosh CL, Clark RE. Tricuspid regurgitation in patients with acquired, chronic, pure mitral regurgitation. J Thorac Cardiovasc Surg 1987;94:488–97.[Abstract]
8. Davila JC. Adjustable annuloplasty for tricuspid insufficiency. Ann Thorac Surg 1989;47:639–40.
9. Rowlatt UF, Rimoldi HJA, Lev M. The quantitative anatomy of the normal child's heart. Pediatr Clin North Am 1963;10:499–588.
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12. Wei J, Chang CY, Lee FY, Lai WY. De Vega's semicircular annuloplasty for tricuspid valve regurgitation. Ann Thorac Surg 1993;55:482–5.[Abstract]
13. Helmcke F, Nanda NC, Hsiung MC, et al. Color Doppler assessment of mitral regurgitation using orthogonal planes. Circulation 1987;75:175–83.[Abstract/Free Full Text]
14. Simon R, Oelert H, Borst HG, Lichtlen PR. Influence of mitral valve surgery on tricuspid incompetence concomitant with mitral valve disease. Circulation 1980;62(Suppl 1):152–7.
15. De Vega NG. La annuloplastia selectiva, regulable y permanete: una tecnica original para el tratamiento de la insufficiencia tricuspide. Rev Esp Cardiol 1972;25:555–6.[Medline]
16. Czer LSC, Maurer G, Bolger A, et al. Tricuspid valve repair: operative and follow-up evaluation by Doppler color flow mapping. J Thorac Cardiovasc Surg 1989;98:101–11.[Abstract]
17. Cohn LH. Invited commentary. In: Wei J, Chang CY, Lee FY, Lai WY. De Vega's semicircular annuloplasty for tricuspid valve regurgitation. Ann Thorac Surg 1993;55:482–5.[Abstract]
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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Jong Bum Choi Hyung Kon Kim Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Choi, J. B. Articles by Jeong, J. W. Search for Related Content PubMed PubMed Citation Articles by Choi, J. B. Articles by Jeong, J. W.