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Triple Valve Repair Supported by Three Remodeling Annuloplasty Rings

Tuesday, May 22, 2018

Badhwar V, Wei LM, Murashita T, Roberts HG, Rankin JS. Triple Valve Repair Supported by Three Remodeling Annuloplasty Rings. May 2018. doi:10.25373/ctsnet.6270173.


The reconstruction of mitral and tricuspid valves during multiple-valve operations reduces mortality risk compared to replacement. Recently, similar findings have been associated with aortic valve repair. To enhance quality and outcome, it might be reasonable to consider conversion to comprehensive aortic, mitral, and tricuspid valve repair in selected patients.

Video Summary

A 77-year-old 60 kg woman presented with persistent atrial fibrillation and presyncope. After guideline directed medical therapy, she persisted with class III congestive heart failure and grade 3 to 4 mitral, aortic, and tricuspid insufficiency, with an ejection fraction of 35%. A strict anterograde and retrograde blood cardioplegia protocol was employed. A biatrial Cox-Maze IV procedure with cryoablation was performed, together with left atrial appendage obliteration. The mitral valve had a rupture of a minor primary chord but overall had good structural support, and it did not require additional artificial chords. The mitral valve was repaired with a #34 mitral remodeling annuloplasty band.

The aortic root was opened with a transverse aortotomy, and traction sutures were placed at the top of all three commissures. The annulus was dilated, and the aortic leaflets were devoid of prolapse. The aortic annulus accepted a #23 Hegar’s dilator. All three leaflets sized to a #19 elliptical aortic annuloplasty ring, which was positioned beneath the annulus with the minor axis post under the left/noncoronary commissure. The posts of the remodeling ring were sutured to the subcommissural spaces using three horizontal mattress sutures of 4-0 polypropylene with fine supra-annular polyester pledgets, and the ring was passed beneath the valve. One looping horizontal mattress suture was inserted per sinus for a total of six sutures, which were then tied. At the end, all three aortic valve leaflets had equivalent effective height and coapted well in the midline.

The grossly incompetent tricuspid valve measured 5 cm by echocardiogram and was repaired with a 28 mm semi-rigid annuloplasty ring, consistent with a tricuspid downsizing philosophy. Aortic clamp and bypass times were 127 and 160 minutes, respectively. On the post-repair echocardiogram, the mitral leaflets moved well with no residual insufficiency. Likewise, the aortic valve was fully competent, with a 9 mm Hg mean systolic pressure gradient. The tricuspid valve was competent and functioned well. The follow-up echocardiogram performed one year postoperatively showed no residual valvular insufficiency, the ejection fraction was 55%, and the patient was in functional class I.


Mitral and tricuspid annuloplasty techniques are well established, with excellent outcomes. The introduction of a remodeling aortic annuloplasty ring provides a straightforward option for addressing aortic insufficiency due to annular dilatation, which augments the efficiency and efficacy of triple valve repair.

Video References

  1. Lee R, Li S, Rankin JS, et al. Fifteen-year outcome trends for valve surgery in North America. Ann Thorac Surg. 2011;91(3):677-684.
  2. Rankin JS, Thourani VH, Suri RM, et al. Associations between valve repair and reduced operative mortality in 21,056 mitral/tricuspid double valve procedures. Eur J Cardiothorac Surg. 2013;44(3):472-477.
  3. Vohra HA, Whistance RN, Hechadi J, et al. Long-term outcomes of concomitant aortic and mitral valve repair. J Thorac Cardiovasc Surg. 2014;148(2):454-460.

Dr Rankin is a consultant for BioStable Science and Engineering in Austin, Texas, and video production was supported by BioStable Science and Engineering.

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