Figure 2.

A, An abnormal tethering of the papillary muscle to the right ventricular wall was released, allowing broader excursion of the leaflets. B, The anteroseptal and posteroseptal commissures were approximated with interrupted sutures. C, Polypropylene sutures in 3 different regions reduced the tricuspid valve annulus. D, Plication of the atrialized portion of the right ventricle inside the heart was done in 2 layers. Interrupted U sutures were applied in the fibrous tissue and to the displaced tricuspid annulus in the first layer. Then the right coronary artery (RCA) wass visualized in the external wall, and another layer of U suture was applied in the wall proximal to the RCA and the fibrous tissue. This technique repositioned the valvar hinge point and the RCA to the atrioventricular junction together without kinking the marginal branches of the RCA. E, Regions of the right atrial (RA) wall that were thin and dilated were trimmed. F, The RA reduction was completed with the atrial closure. G, A 2-year postoperative transthoracic echocardiogram shows mild tricuspid regurgitation with unrestricted flow (mean gradient, 2 mm Hg). H, A 2-year postoperative transthoracic echocardiogram shows a color Doppler tricuspid regurgitant gradient of 20 mm Hg.