Tricuspid Valve #6: Ring Annuloplasty

Tricuspid ring annuloplasty is the principal reconstructive strategy for clinically significant tricuspid regurgitation (TR) when annular dilatation and geometric distortion are dominant mechanisms of valve failure. In this setting, the objective is not merely to make the annulus smaller, but to restore a stable, reproducible annular geometry that improves leaflet coaptation and resists late redilatation. Compared with suture-only techniques, ring-based repair has shown superior durability and lower rates of recurrent TR in multiple comparative series and meta-analyses [1-4].

1. Core surgical concept

The central lesion in many patients with functional TR is not isolated leaflet abnormality, but annular enlargement with loss of normal three-dimensional tricuspid geometry, often accompanied by right ventricular (RV) remodeling, papillary displacement, and leaflet tethering [5]. In practical surgical terms, the repair target is therefore the anterior and posterior annulus, where dilatation is most pronounced, rather than the septal annulus, which is relatively fixed and closely related to the conduction system. The goal of ring annuloplasty is to convert a distorted, enlarged annulus into a smaller, more stable, and more coaptation-efficient platform for the native leaflets.

2. Why ring annuloplasty is generally favored

The best available comparative evidence consistently supports ring-based annuloplasty over suture-only reduction for durability. In the Cleveland Clinic experience reported by McCarthy et al., recurrent TR increased significantly over time after De Vega and Peri-Guard repair, whereas regurgitation remained comparatively stable after ring annuloplasty [1]. Parolari et al. demonstrated in meta-analysis that freedom from moderate TR at 15 years was 78.9% with ring annuloplasty versus 60.0% with suture repair [2]. In a later comparative cohort, Adas et al. also found higher early and late recurrence after suture annuloplasty, with reoperation required in 6.85% of the suture group versus 1.3% of the band group during follow-up [3]. Together, these data support the view that when annular deformation is substantial, prosthetic annular remodeling is more durable than tissue-only plication.

3. When ring or band annuloplasty is most appropriate

Ring annuloplasty is particularly appropriate in the following settings:

1. Secondary (functional) TR driven by annular dilatation, RV enlargement, pulmonary hypertension, or chronic right-sided volume/pressure loading.
2. Primary TR with associated annular enlargement, when leaflet tissue remains repairable but annular instability contributes materially to regurgitation.
3. TR with advanced geometric distortion, including leaflet restriction or tethering, in which suture-only repair is unlikely to remain durable.
4. Concomitant left-sided valve surgery, especially when TR is at least moderate or when the annulus is clearly dilated, because untreated annular disease may progress even if the left-sided lesion is corrected [5-8].

4. Operative principle

A practical surgeon-facing sequence is as follows:

1) Define the mechanism precisely

Before committing to annuloplasty alone, determine whether the lesion is dominated by annular dilatation or whether substantial leaflet/subvalvular pathology is also present. This distinction is critical because tethering-dominant TR may require more than annular reduction [5].

2) Place annular sutures where remodeling matters most

Interrupted annular sutures are typically placed along the anterior and posterior annulus, the free-wall segments that dilate most and contribute most to loss of coaptation. The purpose is controlled annular remodeling rather than indiscriminate circumferential tightening.

3) Respect the septal annulus and conduction zone

The septal annulus lies adjacent to Koch’s triangle and the AV nodal region. For that reason, repair is commonly designed to reshape the annulus while avoiding unnecessary fixation or distortion in the conduction-sensitive septal area. In operative terms, this is one reason many surgeons favor an incomplete ring or band configuration in routine tricuspid repair.

4) Implant the prosthesis to restore geometry, not simply reduce size

A ring or band reduces annular circumference, decreases septolateral dimension, and re-establishes a more stable coaptation plane. The conceptual advantage is structural: the annuloplasty device provides a scaffold against future redilatation, something suture-only repair cannot do as reliably [1-5].

5) Test the repair carefully

Saline testing and intraoperative echocardiography should evaluate residual TR, leaflet mobility, coaptation depth, and any evidence of iatrogenic stenosis or restricted opening.

5. Predictors of failure and the limits of annuloplasty alone

A high-quality tricuspid repair depends not only on annular reduction, but on whether the leaflets can actually meet after remodeling. This is the major limitation of annuloplasty-only thinking. In tethering-dominant TR, the annulus may be reduced appropriately while the leaflets remain displaced apically and laterally, resulting in residual or recurrent regurgitation. Contemporary reviews therefore emphasize that TR surgery should be framed in terms of annulus + leaflet tethering + RV remodeling, not annular size alone [5].

Several factors have been associated with recurrent TR after repair. McCarthy et al. identified higher preoperative TR grade, poor LV function, permanent pacemaker presence, and non-ring repair type as risk factors for worsening regurgitation [1]. Gatti et al. similarly found that LVEF <50%, tricuspid annular diameter >40 mm, and use of De Vega annuloplasty predicted recurrent grade ≥2+ TR during follow-up [4]. These observations are clinically important because they support earlier intervention before profound annular and ventricular remodeling become fixed.

6. Ring choice: practical interpretation

In everyday surgical practice, the prosthesis is often an incomplete ring or band rather than a complete circumferential device. The rationale is anatomical and biomechanical:

• the anterior and posterior annulus are the principal sites of pathologic dilatation;
• the septal annulus is less distensible and more closely related to the conduction system;
• the aim is to reshape the annulus selectively and safely, rather than to impose uniform circumferential restriction.

The literature most strongly supports the general superiority of device-based annuloplasty over suture-only repair [1-5]. Comparative evidence between rigid rings, semi-rigid rings, and flexible bands is less uniform, although several reviews conclude that rigid or semi-rigid rings offer the most reproducible long-term annular stability [1,5].

7. Post-repair hemodynamic thinking

A technically sound ring annuloplasty can still fail physiologically if the right heart remains exposed to adverse loading conditions. Postoperative management should therefore include:

• optimization of RV preload without overdistention,
• reduction of pulmonary vascular resistance
• treatment of residual left-sided valve disease or pulmonary hypertension,
• and attention to atrial fibrillation/right atrial enlargement, which can perpetuate annular stress.

This broader framework reflects the modern understanding that TR is part of a right-heart structural and hemodynamic syndrome, not merely a local leaflet problem [5-7].

8. Contemporary guideline-level perspective

Current North American and European guidelines endorse a more proactive approach to tricuspid intervention than in prior eras. In patients undergoing left-sided valve surgery, tricuspid repair is recommended for severe TR and is also supported for less-than-severe TR when annular dilatation is present, commonly defined as >40 mm or >21 mm/m² [6,7]. This shift reflects the recognition that delayed referral leads to more advanced RV remodeling, more recurrent TR, and worse late outcomes. Recent randomized data have further reinforced this direction: in patients undergoing mitral surgery for degenerative mitral regurgitation, concomitant tricuspid annuloplasty reduced the 2-year composite of TR progression, severe TR, reoperation, or death compared with mitral surgery alone [8].

Refined take-home message

Ring annuloplasty is the standard durable repair platform for annular-dominant tricuspid regurgitation. Its major advantage over suture-only repair is not merely smaller annular size, but stable geometric remodeling with better resistance to recurrent dilatation [1-4]. However, the annulus is only one part of the disease. Durable repair also requires recognition of leaflet tethering, RV remodeling, loading conditions, and associated leaflet/subvalvular pathology, because annuloplasty alone may be insufficient when TR is no longer purely annular [4,5].

References

[1] McCarthy PM, Bhudia SK, Rajeswaran J, Hoercher KJ, Lytle BW, Cosgrove DM, Blackstone EH. Tricuspid valve repair: durability and risk factors for failure. J Thorac Cardiovasc Surg. 2004;127(3):674-685.

[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] Adas A, Elnaggar A, Balbaa Y, Elashkar A, Alkady HM. Ring, Band or Suture in Tricuspid Annuloplasty for Functional Tricuspid Regurgitation; Which is Better and More Durable? Heart Surg Forum. 2019;22(5):E411-E415.

[4] Gatti G, Dell'Angela L, Morosin M, Maschietto L, Pinamonti B, Forti G, Benussi B, Nicolosi GL, Sinagra G, Pappalardo A. Tricuspid Annuloplasty for Tricuspid Regurgitation Secondary to Left-Sided Heart Valve Disease: Immediate Outcomes and Risk Factors for Late Failure. Can J Cardiol. 2016;32(6):760-766.

[5] Watt TMF, Dreyfus GD. Functional tricuspid regurgitation: indications, techniques, and outcomes. Indian J Thorac Cardiovasc Surg. 2020;36(Suppl 2):227-235.

[6] Writing Committee Members, Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP 3rd, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM 3rd, Thompson A, Toly C. 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol. 2021;77(4):e25-e197.

[7] Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W; ESC/EACTS Scientific Document Group. 2021 ESC/EACTS Guidelines for the management of valvular heart disease. Eur Heart J. 2022;43(7):561-632.

[8] Gammie JS, Chu MWA, Falk V, Overbey JR, Moskowitz AJ, Gillinov M, Mack MJ, Voisine P, Krane M, Yerokun B, Bowdish ME, Conradi L, Bolling SF, Miller MA, Taddei-Peters WC, et al. Concomitant Tricuspid Repair in Patients with Degenerative Mitral Regurgitation. N Engl J Med. 2022;386(4):327-339