Complete mapping of the tricuspid valve apparatus using three-dimensional sonomicrometry

OBJECTIVE: Many surgeons consider the tricuspid valve to be a second-class structure. Our objective was to determine the normal anatomy and dynamic characteristics of the tricuspid valve apparatus in vivo and to discern whether this would aid the design of a tricuspid valve annuloplasty ring model.METHODS: Sixteen sonomicrometry crystals were placed around the tricuspid annulus, at the bases and tips of the papillary muscles, the free edges of the leaflets, and the right ventricular apex during cardiopulmonary bypass in 5 anesthetized York Hampshire pigs. Animals were studied after weaning of cardiopulmonary bypass on 10 cardiac cycles of normal hemodynamics. RESULTS: Sonomicrometry array localizations demonstrate the multiplanar shape of the tricuspid annulus. The tricuspid annulus reaches its maximum area (97.9 +/- 25.4 mm(2)) at the end of diastole and its minimum area (77.3 +/- 22.5 mm(2)) at the end of systole, and increases again in early diastole. Papillary muscles shorten by 0.8 to 1.5 mm (11.2%) in systole, and chordae tendineae straighten by 0.8 to 1.7 mm (11.4%) in systole. CONCLUSIONS: The shape of the tricuspid annulus is a multiplanar 3-dimensional one with its highest point at the anteroseptal commissure and its lowest point at the posteroseptal commissure, and the anteroposterior commissure is in a middle plane in between. The tricuspid annulus area reaches its maximum during diastole and its minimum during systole. The papillary muscles contract by the same amount of chordal straightening. The optimal tricuspid annuloplasty ring may be a multiplanar 3-dimensional one that mimics the normal tricuspid annulus