A modified technique for supra-annular implantation of prosthetic tricuspid valve

In conventional tricuspid valve replacement, there is a risk of valve detachment because stitches are placed on relatively fragile tissues. In the supra-annular implantation technique, stitches are placed lateral to the triangle of Koch and the coronary sinus instead of the anterior and septal leaflets as in conventional tricuspid valve replacement. This procedure relieves stress at the antero-septal commissural area, as well as avoids injury to the conduction system. However, there are a few drawbacks: (1) the valve sits obliquely at the annular surface, (2) the suture line becomes extremely long, and (3) the venous return to the coronary sinus may be impeded. We modified the suture line, which travels lateral to the triangle of Koch and medial to the coronary sinus, to solve these problems. We herein report the technique and results of four cases.