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Place the sizer (with the “T” showing) over the

unfurled anterior tricuspid leaflet (ATL ) with the notches

at each end of the septal leaflet

Choose the sizer which best approximates the

surface area of the ATL

With the straight side of the sizer against the septal

annulus, place the “last” suture in the septal annulus

corresponding to the location of the last half oval

marking before the open space

Using the suture guides on the holder, place the

individual mattress sutures through the suture platforms

leaving the UniRing® on the holder. The “first” suture should be placed in the vertical part of the anterior annulus just above the anterior-septal commissure

Use 2/0 or 3/0 sutures (Cardioflon®) for the tricuspid

annulus

Tie each mattress suture firmly with 7 knots

Place one suture at each commissure and use lateral traction to straighten the anterior annulus, and place one suture (“middle” suture) in the centre of the posterior annulus (P2)

Place additional sutures in the annulus if necessary in order to visualize the unfurled anterior mitral leaflet (AML)

Place the sizer (with the “M” showing) over the AML with the notches at the commissures With the sizer against the anterior annulus, place the two intercommissural sutures in the annulus

corresponding to the desired location of the “first” and “last” suture-platforms as indicated by the half-oval markings on the sizer, depending upon how far around the annulus the surgeon chooses to go

Using the suture guides on the holder, place the individual mattress sutures through the suture platforms leaving the Uniring® on the holder Use 2/0 sutures (Cardioflon®) for the mitral annulus

Once all sutures are placed one-to-one in the Uniring®, cut at the appropriate heat-sealed joints using a sharp blade in the cutting guide on the outside edge of the “first” and “last” suture-platforms

With the Uniring® free of the holder, slide the Uniring® onto the annulus

For annular stabilization without plication (as is usual in the anterior mitral annulus), the sutures should incorporate exactly 3 mm of tissue, corresponding to the precise distance between the 2 holes in each suture platform

For annular plication (as is usual in the posterior mitral and anterior and posterior tricuspid annulus), larger amounts of tissue (> 3 mm) are incorporated within each horizontal mattress suture loop underneath the suture-platform

Closed Ring

Open Ring

There must be a 3 mm space of tissue between individual mattress sutures to accommodate the flexible joints of UniRing®

Individual braided polyester horizontal mattress sutures are placed one-to-one in the tissue annulus corresponding to the number of suture-platforms needed

T he gaps between the “middle” sutures and the “first” and “last” sutures, (and any additional suture used for exposure of the anterior leaflet), should be made up with the exact number of sutures according to the total number of suture-platforms indicated on the sizer

TRICUSPID

MITRAL

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