Tricuspid Valve #5: DeVega Annuloplasty
1. Core concept
De Vega annuloplasty is a classic suture-based tricuspid annuloplasty designed primarily for functional (secondary) tricuspid regurgitation (TR) in which the dominant lesion is annular dilatation, while leaflet tissue remains reasonably preserved and there is no major organic leaflet destruction, severe restriction, or tethering-dominant subvalvular distortion [1,4,5]. In this setting, the principal surgical target is not the leaflet itself, but the dilated annulus, particularly the anterior and posterior annular segments along the RV free-wall side.
2. Mechanistic rationale
The operative goal of De Vega repair is to restore leaflet coaptation by controlled annular reduction. This concept remains sound when TR is driven predominantly by annular enlargement, especially in the context of concomitant left-sided valve disease [1,4,5]. However, the durability of annuloplasty depends on whether annular dilatation is the main problem or merely one component of a broader disease process that also includes RV remodeling, pulmonary hypertension, atrial fibrillation, or leaflet tethering [1,2,6].
3. When De Vega repair is most suitable
A De Vega repair is most appropriate in the following setting:
- Functional TR with annular enlargement
- No major organic leaflet pathology
- A situation in which a rapid, simple, prosthesis-free repair is advantageous
The lesion is annular and geometric rather than destructive; leaflet mobility is relatively preserved and coaptation can be improved by downsizing the annulus [1,4].
Cases with severe leaflet perforation, marked dysplasia, endocarditic destruction, or advanced retraction usually require a different repair strategy or replacement rather than isolated annuloplasty [1,2].
This remains one of the enduring strengths of De Vega annuloplasty, particularly during concomitant mitral or multivalve surgery [1,4,5].
4. Operative principle
The essence of the De Vega technique is a running semicircular annuloplasty suture, classically performed as a double continuous plication, placed along the anterior and posterior annulus to reduce annular circumference in a controlled fashion [4,7]. Modified techniques commonly use pledget-supported sutures or two separate semicircular sutures to distribute tension more evenly and reduce the risk of suture cut-through [4,7]. In practical terms, the operation can be conceptualized as follows:
- define the mechanism: annular dilatation rather than primary leaflet disease
- place annuloplasty sutures along the free-wall annulus
- downsize the annulus gradually and symmetrically
- assess competence immediately with a saline test and intraoperative echocardiography [4,7]
5. Why the septal annulus is treated differently
Although the comparative outcome literature focuses mainly on recurrence and durability rather than detailed conduction outcomes, surgical technique traditionally avoids aggressive plication across the septal annulus because of its proximity to the atrioventricular conduction region. Accordingly, De Vega repair is generally concentrated on the anterior–posterior annular arc, where functional dilatation is usually greatest [4,7]. This principle is anatomically logical and remains an important operative safeguard, although large comparative studies do not specifically quantify conduction-injury risk as a primary endpoint [1,7].
6. Technical pearls
Several technical points improve the quality of a De Vega repair:
- Controlled reduction, not over-plication
- Pledgets help distribute force
- The repair must be judged functionally, not visually alone
The aim is to restore coaptation without creating functional stenosis or distorting leaflet motion. Indexed annular reduction may matter; in one long-term series, larger residual indexed annular size predicted recurrent TR, underscoring the importance of adequate but not excessive downsizing [6].
Modified De Vega techniques using felt-supported bites were developed to lower local stress concentration and reduce annular tearing or suture cut-through [4,7].
A smaller annulus does not automatically mean a competent valve. Saline insufflation and intraoperative echocardiography remain essential to assess residual TR, coaptation quality, and the adequacy of annular reduction [7].
7. Outcomes and durability
The contemporary evidence suggests a nuanced view of De Vega annuloplasty rather than a simple endorsement or rejection.
In a 448-patient comparative study, early mortality was similar between modified De Vega and ring annuloplasty (0.9% vs 1.3%), both techniques significantly reduced TR grade, and 5-year survival was comparable (84% vs 82%), but recurrence-free survival numerically favored ring annuloplasty (78.8% vs 74.5%) [1]. A meta-analysis likewise found that ring annuloplasty was associated with better freedom from recurrent moderate TR over long-term follow-up, supporting the view that ring annuloplasty is generally more durable for many patients [2]. Older comparative series also reported markedly lower recurrence after ring repair than after De Vega repair in secondary TR [3].
At the same time, not all datasets show a strong long-term disadvantage for De Vega. A 570-patient study reported similar 10-year recurrence of severe TR (5.8%) in ring and De Vega groups, suggesting that when a standardized modified De Vega technique is used in selected patients, durability can be acceptable [5]. Similarly, other institutional series found no significant difference in long-term mortality or recurrent TR trends between ring and suture techniques in selected concomitant mitral surgery populations [6]. Therefore, the most defensible interpretation is that De Vega is acceptable for properly selected annular functional TR, but ring annuloplasty remains the more reproducibly durable option in broader or more advanced disease [2,5,6].
8. Risk factors for recurrence
Recurrent TR after De Vega repair is not random. Available data identify several predictors of late failure, including:
- greater preoperative TR severity
- atrial fibrillation
- pulmonary hypertension
- inadequate annular reduction relative to body size [1,6]
These findings reinforce a key surgical principle: De Vega works best when the pathology is truly annular-dominant, and when annular reduction is calibrated appropriately rather than performed empirically [1,6].
9. Contemporary perspective
From a modern surgeon-facing standpoint, TR should be repaired according to mechanism, not treated as a uniform lesion. De Vega annuloplasty remains an elegant and efficient repair for simple annular functional TR, especially when leaflet tissue is preserved and the operation requires a straightforward prosthesis-free annuloplasty [1,4,5]. However, in patients with advanced RV remodeling, marked annular deformation, significant tethering, pulmonary hypertension, or higher recurrence risk, many surgeons favor ring annuloplasty because of its greater geometric stability and more consistent long-term resistance to redilatation [2,3,6].
10. High-yield take-home message
De Vega annuloplasty remains a valid repair for selected functional TR driven predominantly by annular dilatation. Its strengths are simplicity, speed, low prosthetic burden, and technical adaptability. Its principal limitation is durability, particularly when TR reflects more than annular enlargement alone. The best results are obtained when the surgeon selects the technique based on mechanism, performs controlled annular reduction, uses tension-distributing modifications when needed, and confirms competence with immediate intraoperative testing [1,2,4,6,7].
References
[1] Huang X, Gu C, Men X, Zhang J, You B, Zhang H, Wei H, Li J. Repair of functional tricuspid regurgitation: comparison between suture annuloplasty and rings annuloplasty. Ann Thorac Surg. 2014;97(4):1286-1292.
[2] Parolari A, Barili F, Pilozzi A, Pacini D. Ring or suture annuloplasty for tricuspid regurgitation? A meta-analysis review. Ann Thorac Surg. 2014;98(6):2255-2263.
[3] Matsuyama K, Matsumoto M, Sugita T, Nishizawa J, Tokuda Y, Matsuo T, Ueda Y. De Vega annuloplasty and Carpentier-Edwards ring annuloplasty for secondary tricuspid regurgitation. J Heart Valve Dis. 2001;10(4):520-524.
[4] Aoyagi S, Tanaka K, Hara H, Kumate M, Oryoji A, Yasunaga H, Kosuga K, Ohishi K. Modified De Vega's annuloplasty for functional tricuspid regurgitation--early and late results. Kurume Med J. 1992;39(1):23-32.
[5] Csanády J, Kurfirst V, Frána R, Mokráček A. De Vega tricuspid valve annuloplasty - a rightly neglected surgical technique? Kardiochir Torakochirurgia Pol. 2018;15(2):95-101.
[6] Hwang HY, Chang HW, Jeong DS, Ahn H. De Vega annuloplasty for functional tricuspid regurgitation: concept of tricuspid valve orifice index to optimize tricuspid valve annular reduction. J Korean Med Sci. 2013;28(12):1756-1761.
[7] Tanaka M, Takeuchi E, Watanabe T, Hota T, Tamaki S, Tajima I, Maseki T, Sawazaki M, Hirate Y, Abe T. [Tricuspid annuloplasty--modified technique]. Nihon Kyobu Geka Gakkai Zasshi. 1990;38(10):2034-2038.