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Background For repairing severe tricuspid regurgitation (TR) with leaflet tethering, our team employs spiral suspension procedure, in which papillary muscles (PMs) are approximated and suspended towards annulus by suture in addition to annuloplasty. Purpose To visualize subtricuspid apparatus and investigate its geometric change by the procedure, comparing with annuloplasty alone. Methods 11 patients who underwent spiral suspension and 10 patients who underwent annuloplasty alone were studied. Using 3D dataset derived from transesophgeal echocardiography with transgastric approach, the distances between the mid septal annulus (point C) and the anterior PM tip (point A) and posterior PM (point P) were calculated. Also, annular perimeter, leaflet surface area and tenting height were measured Results In all cases, PM tips could be visualized and identified for the measurements. By spiral suspension, the distance CA and tenting height were significantly reduced. On the other hand, by annuloplasty alone, CA and tenting height were likely to be increased but statistically not significant. Conclusions Spiral suspension ameliorated leaflet tethering with relocating PMs. Annuloplasty alone reduced leaflet surface area, which indicates increase of coaptation surface. Interestingly, PM tip- annulus distance and tenting height were possibly increased by annuloplasty. Further investigation is need in large number. Result of measurements Annuloplasty alone Spiral suspension Pre-op Post-op Pre-op Post-op Annular perimeter, mm 120.9 ± 11.2 78.8 ± 5.1* 142.4 ± 18.2* 81.1 ± 6.4** Leaflet surface area, cm2 13.1 ± 3.1 5.6 ± 0.9* 19.3 ± 4.8* 5.8 ± 0.8** Tenting height, mm 2.8 ± 2.3 3.1 ± 1.2 7.0 ± 4.8* 2.9 ± 2.6** CA, mm 27.3 ± 3.9 29.1 ± 6.2 35.7 ± 6.9* 29.6 ± 5.2** CP, mm 33.1 ± 6.0 33.8 ± 9.4 38.5 ± 8.2 33.9 ± 6.1 *p &amp;lt; 0.05, vs Annuloplasty alone pre-op **p &amp;lt; 0.05, vs Spiral suspension pre-op Abstract 41 Figure. Pre- and post-operative valve apparatus

41 Geometric change in valvular apparatus during tricuspid repair for severe tricuspid regurgitation