cardiac enlargement, when the anatomy suggests a high probability of successful valve repair Early67–69 and intermediate follow-up studies have demonstrated low early mortality and improved freedom from late reoperation.47,70–73 Operative management consists of tricuspid valve repair, selective plication of the atrialized RV, right reduction atrioplasty, closure (or subtotal closure) of any atrial level shunts, and correction of associated anomalies.44,64 Tricuspid valve replacement is reserved for valves not amendable to repair, older adults (>60 years of age), cases with massive right ventricular or tricuspid annular dilatation, and mild-moderate pulmonary hypertension Intraoperative transesophageal echocardiography is used routinely Arrhythmia procedures at the time of surgery are (cryoablation or radiofrequency ablation) performed as indicated and include a modified rightsided maze and cavotricuspid isthmus ablation for paroxysmal atrial fibrillation or atrial flutter, and left atrial maze or pulmonary vein isolation procedure is applied for continuous atrial fibrillation.74,75 When there has been percutaneous radiofrequency ablation prior to surgery, surgical maze lesions are generally more limited in an effort to avoid a slow junctional rhythm or complete heart block postoperatively that would require permanent pacing When permanent pacing is required, we generally prefer epicardial pacing In the rare situation when there is significant left ventricular dysfunction, biventricular pacing is preferred Tricuspid Valve Repair and Replacement The early era of tricuspid valve repair focused on the concept of a functional monocusp that depended on an adequate anterior mobile leaflet that allowed coaptation with the ventricular septum The Mayo Clinic (Danielson) method addressed the valve where it resided in the ventricle and typically included the use of a Sebening stitch that approximated the major anterior papillary muscle(s) to the ventricular septum76,77 and included selective plication of the atrialized right ventricle The French experience (Carpentier-Chauvaud) was also a monocusp technique and focused on mobilization (surgical delamination) of the tethered anterior leaflet with reattachment to the anterior annulus and placement of a ring and plication of the aRV.78,79 The contemporary era of tricuspid repair was popularized in Brazil (da Silva) —the cone reconstruction—and was an extension of the French technique.80 The principle of cone repair is complete surgical delamination and recruitment of all undelaminated leaflet tissue that is then reanchored at the anatomic right atrioventricular junction, creating a 360-degree “leaflet cone.” The unique features of this surgical reconstruction are highlighted in Figs 33.18 to 33.27 The atrialized, inferior right ventricle (i.e., smooth and nontrabeculated) is plicated internally from “apex to annulus.” Care is taken to avoid distortion or compromise of the right coronary artery or its branches Additional annular plication sutures are placed as needed to reduce annular size to match the smaller neotricuspid valve orifice A flexible annuloplasty band (anteroseptal commissure clockwise to coronary sinus) can be used to stabilize the repair When somatic growth is a concern, partial band support from anteroinferior commissure to coronary sinus may be applied because this is the area under greatest tension The septal leaflet reattachment is done to the ventricular septum just caudal to the conduction tissue The reattachment of the reconstructed circumferential neotricuspid valve with its hinge point at the atrioventricular groove mimics normal tricuspid anatomy, creating a nearly “anatomic repair.” Early to intermediate experience of the cone repair has been excellent with low early mortality ranging from 1% to 3% and freedom from reoperation of approximately 95% at 5 to 10 years.80–83 The echocardiographic features of this reconstruction are illustrated in Figs 33.15 and 33.28, as well as Videos 33.3 to 33.6 The surgical procedure, supplemented by echocardiographic clips from the same patient, is highlighted in Video 33.7 FIG 33.18 Surgeon's view from the right atrium during cardiopulmonary bypass Shown are aortic and bicaval cannulation with aortic occlusion and cardioplegic arrest The tricuspid valve (TV) is displaced apically and rotated toward the right ventricular outflow tract, creating an atrialized segment of the right ventricle between the TV leaflets and the true tricuspid annulus (TTA) The membranous septum and vein of D mark the location of the atrioventricular node CS, Coronary sinus; IVC, inferior vena cava; PFO, patent foramen ovale; PT, pulmonary trunk; SVC, superior vena cava