FIG 33.22 Cone reconstruction of the tricuspid valve The mobilized anterior leaflet is rotated clockwise to meet the proximal mobilized edge of the septal leaflet (left) This completes the “cone,” creating 360 degrees of circumferential leaflet tissue This suture line (right) is done with a running suture that is locked with every other stitch to avoid a purse-string effect that would shorten the height of the leaflet cone FIG 33.23 Cone reconstruction of the tricuspid valve After the leaflet reconstruction is completed, the atrialized segment of right ventricle will be plicated The blue dashed lines, in the shape of a triangle, outline the thinned area of atrialization that will be included in the plication This area is excluded from the functional ventricular chamber postoperatively and results in a blind pouch of inferior wall that is noncontractile The base of the triangle just crosses the atrioventricular groove, which will be reduced in size by this maneuver The shaded, “hatched” dashed line in the background of the anterior and lateral atrioventricular groove denotes the course of the right coronary artery FIG 33.24 Cone reconstruction of the tricuspid valve This figure shows the completed plication of the atrialized right ventricle (shown with the needle still attached to the suture line) and the adjacent “cone” of reconstructed leaflet tissue (which is still detached from the annulus) Note that the atrioventricular groove has been reduced in size and is now closer to the size of neotricuspid valve orifice (cone) It is important to examine the exterior surface of the heart at this stage to ensure that there has been no compromise of the right coronary (shaded, “hatched” dashed line) or posterior descending coronary artery