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  • Review Article
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Evidence-based surgical management of acquired tricuspid valve disease

Abstract

Tricuspid valve (TV) disease most often occurs secondary to left-sided heart disease, particularly mitral valve (MV) regurgitation or stenosis. Appropriate treatment, even when TV regurgitation is secondary to left-sided heart disease, can improve long-term outcome. Valvuloplasty is the most common procedure for TV disease, and has received an increasing amount of attention, as right-sided heart failure combined with TV regurgitation is associated with poor long-term outcome. Although some controversies exist regarding the indication and timing of the TV operation, concomitant surgical repair of TV regurgitation at the time of MV surgery should be considered, as this procedure improves perioperative outcomes, functional class, and survival. Importantly, TV repair does not increase operative mortality. In our experience, both suture annuloplasty and partial ring annuloplasty give satisfactory results, and bioprosthetic valves can be used when leaflets are damaged and the TV annulus is extremely dilated.

Key Points

  • Functional tricuspid regurgitation is the most common type of tricuspid valve (TV) disease that develops secondary to tricuspid annular and right ventricular dilatation, and is often reversible

  • Organic TV disease results from primary structural pathology in leaflets, subvalvular apparatus, or both, with or without a dilated annulus; the most common cause is rheumatic fever

  • For isolated severe TV disease, surgery should be considered before severe functional limitation and hepatic dysfunction occur, particularly when the right ventricle is markedly enlarged and systolic function is impaired

  • Correct TV repair gives excellent results; however, late failure occurs in a substantial proportion of patients, and the clinical challenges are the appropriate selection of patients and the repair technique

  • The choice between mechanical and bioprosthetic valves remains controversial; however, bioprosthetic valves are generally preferred in patients aged >65 years, whereas mechanical valves are preferred in younger patients

  • Acute kidney injury following TV surgery is not uncommon, but the pathophysiology is not well understood; impaired renal blood flow caused by left ventricular dysfunction is one mechanism

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Figure 1: Pathophysiology of functional tricuspid regurgitation.6
Figure 2: Dilatation of the tricuspid annulus in patients with TR.
Figure 3: Clinical outcome of patients with tricuspid regurgitation caused by flail leaflets.
Figure 4: Surgical view of the tricuspid valve through a standard right atriotomy.
Figure 5: Various tricuspid valve annuloplasty procedures.

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Both authors contributed substantially to researching data, discussion of content, writing, and reviewing and editing the manuscript before submission.

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Shinn, S., Schaff, H. Evidence-based surgical management of acquired tricuspid valve disease. Nat Rev Cardiol 10, 190–203 (2013). https://doi.org/10.1038/nrcardio.2013.5

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