Echo-Guided Commissural Edge-to-Edge Suture for Repair of Secondary Tricuspid Regurgitation

The management of secondary tricuspid regurgitation (TR) is rapidly evolving with the availability of tricuspid transcatheter edge-to-edge (T-TEER). In the evaluation of TR, the subtending mechanism (annular dilatation, symmetric or asymmetric leaflet tethering, or a combination of them) is reflected by the topography of the regurgitant jet (central, located in the anteroseptal or posteroseptal commissure, or a combination of them). Ring annuloplasty is a mainstem of surgery for TR. We propose the suture of the anteroseptal or posteroseptal commissure, complementary to ring annuloplasty, on the basis of regurgitant jet location as evident on transesophageal echocardiography. The aim is to improve the correction of TR and its durability, by addressing the topography of TR and the subtending mechanism (such as asymmetric restriction of the septal leaflet) in a more specific way. This strategy relies on the current approach to the appreciation of TR as developed in the context of T-TEER planning and performance. We present two cases illustrating this modified operative approach.