Tricuspid Valve Repair

Anatomy and Physiology

Of all the valves in the heart, the tricuspid valve is the largest and most apically placed between the right atrium and the right ventricle. The valve consists of 3 leaflets, namely septal, anterior, and posterior, with a normal valve area of 7 to 9 cm².[17] The tricuspid valve complex comprises the leaflets, annulus, chordae, papillary muscles, and attached right ventricle segment.[18][19][20] The mean pressure gradient across the tricuspid valve is less than 2 mm Hg, and the peak velocity across the valve is less than 1 m/s due to the large size of the valve and lower pressures on the right side of the heart. There are reported variants of the tricuspid valve with 2 or more than 3 cusps.[21] 

The anterior (or attitudinally anterosuperior) leaflet is the largest of the 3 leaflets with the greatest motion. The septal leaflet is the least mobile and attached to the septum less than 10 mm apically from the septal insertion of the anterior mitral leaflet, a distinguishing feature helpful in diagnosing Ebstein anomaly when it is tethered to the right ventricular wall, giving it an echocardiographic appearance of greater than 10 mm apical attachment and causing atrialization of the right ventricle with severe tricuspid regurgitation. The posterior (or attitudinally inferior) leaflet is the shortest circumferentially. The coaptation point of the leaflets is at or below the level of the annulus. The coaptation length is 5 to 10 mm, allowing more valve area in case of annular dilatation before failure to coapt.[22]

Usually, there are 2 papillary muscles, anterior and posterior, with a third variable septal papillary muscle. The anterior papillary muscle is the largest, and attached chordae support the anterior and posterior leaflets. The moderator band sometimes joins this papillary muscle. The posterior papillary muscle can be bifid or trifid, and the attached chordae support posterior and septal leaflets. The tricuspid annulus is a dynamic and D-shaped structure, with a larger semicircular C-shaped segment correlating with the free wall of the right ventricle and a shorter and straighter segment associated with the septum.

Pathophysiology of Tricuspid Regurgitation 

The 2 main tricuspid regurgitation types are primary and secondary (functional). The most common etiology of tricuspid regurgitation is secondary (functional), and its incidence is approximately 90% among patients with tricuspid regurgitation.[23] Primary tricuspid regurgitation is less common and caused by anatomical involvement of tricuspid valve structures; this condition is usually due to a congenital or acquired etiology affecting leaflets or chordae. In secondary (functional) tricuspid regurgitation, leaflets and chords are normal, and tricuspid regurgitation occurs due to atrial and ventricular dilatation, annular dilation, and chordal tethering. The most common causes of secondary tricuspid regurgitation are left-sided valvular or myocardial pathologies and pulmonary hypertension. 

The following are the causes of tricuspid regurgitation:

• Primary tricuspid regurgitation 
  • This type can be further divided into 2 categories:
    • Congenital
      • Ebstein anomaly
      • Tricuspid valve hypoplasia, clefts
      • Double orifice valve
    • Acquired
      • Prolapse or flail of tricuspid valve leaflets due to myxomatous degeneration
      • Carcinoid syndrome
      • Tricuspid valve endocarditis
      • Related to a pacemaker and implantable cardiac device
      • Rheumatic disease
      • Traumatic injury to the valve structures (chest trauma or iatrogenic with right-sided intracardiac procedures)
• Secondary tricuspid regurgitation 
  • Left-sided valvular heart diseases (mitral valve stenosis/regurgitation)
  • Left ventricular dysfunction
  • Primary or secondary pulmonary hypertension
  • Right atrial enlargement (in atrial fibrillation)
  • Right ventricular dysfunction and dilatation (remodeling after right ventricular infarct)
  • Tricuspid annular dilatation [20]

Indications

The American College of Cardiology/American Heart Association guidelines recommend tricuspid valve surgery. The only class 1 indication for tricuspid valve surgery is during left-sided valve procedures. For isolated tricuspid valve surgery, the guidelines recommend intervention for patients with symptoms of right-sided heart failure (class 2a) or asymptomatic individuals with primary tricuspid regurgitation and worsening right ventricular function (class 2b). Consequently, many patients undergo treatment later in the disease course. Evidence supporting early intervention for severe tricuspid regurgitation and optimal timing remains limited. However, the latest guidelines emphasize that treating primary tricuspid regurgitation before significant right ventricular dysfunction or end-organ damage is ideal.[24][25]

Isolated tricuspid valve repair is uncommon, even though tricuspid valve abnormalities can result in significant morbidity and mortality. Most tricuspid valve procedures are performed secondarily with other primary cardiac surgical procedures. The most common indication is to perform tricuspid valve surgery in patients with symptomatic severe primary tricuspid regurgitation.[26][27] The following are the indications for tricuspid valve repair or replacement:

• Symptomatic severe tricuspid stenosis
• Severe tricuspid stenosis without symptoms when the patient is undergoing left-sided valve surgery
• Symptomatic severe primary or secondary tricuspid regurgitation
• Severe primary or secondary tricuspid regurgitation (symptomatic or asymptomatic) when the patient is undergoing left-sided valve surgery
• Moderate to severe primary tricuspid regurgitation when the patient is undergoing left-sided valve surgery
• Asymptomatic or mildly symptomatic primary tricuspid regurgitation with evidence of progressive right ventricular dilatation and dysfunction
• Mild or moderate progressive functional (secondary) tricuspid regurgitation with a dilated annulus (≥40 mm or ≥21 mm/m²) when the patient is undergoing left-sided valve surgery 
• Tricuspid valve endocarditis
• Carcinoid involvement of the tricuspid valve 
• Congenital malformations (eg, Ebstein anomaly)
• Traumatic or iatrogenic injuries to the valve when taking biopsies or from pacemaker leads

A murmur associated with tricuspid valve regurgitation is typically high-pitched and holosystolic, best heard at the fourth intercostal space along the parasternal region using a stethoscope. The intensity of the murmur increases during inspiration due to augmented venous return to the right heart and diminishes when standing or during a Valsalva maneuver. The murmur may also radiate to the right lower sternal border, reflecting the regurgitant blood flow through the tricuspid valve. This murmur can be detected during a physical examination or confirmed through echocardiography. Additional signs of tricuspid valve regurgitation may include:

• A pronounced pulse in the neck or near the liver
• Fatigue, particularly during exertion
• Swelling in the abdomen, legs, or neck veins

A recent review explored the effectiveness of an algorithm for determining the severity of tricuspid regurgitation. The results showed that severe tricuspid regurgitation was identified based on a suggestive color Doppler jet and the presence of 1 or more of the following criteria:

• Inferior vena cava diameter greater than 2.5 cm and right atrial area exceeding 18 cm², in the absence of atrial septal defect or pulmonic valve disease
• Jet area larger than 10 cm² and vena contracta width exceeding 7 mm
• Systolic flow reversal in the hepatic veins, provided there is no atrioventricular dissociation, ventricular pacing, or atrial arrhythmia
• A triangular continuous wave Doppler signal with a density comparable to or greater than tricuspid inflow

These parameters strongly correlate with expert interpretations and magnetic resonance imaging-measured regurgitant volume and fraction (>48% for severe tricuspid regurgitation). Additionally, they improved consistency among observers.[28]

Technique or Treatment

Surgical Repair of the Tricuspid Valve

Tricuspid regurgitation is the most common reason for patients undergoing surgical tricuspid valve repair. Further, those with secondary (functional) tricuspid regurgitation most likely undergo repair. In contrast, patients with primary tricuspid regurgitation are not considered suitable for repair due to pathology involving multiple leaflets, and replacement results are better. Tricuspid valve repair reduces the annular diameter and right ventricular afterload but increases valvular coaptation. Important anatomic considerations for the surgeon include the presence of the atrioventricular node and conducting system within the triangle of Koch demarcated as the base of the Todaro septal leaflet, coronary sinus orifice, and tendon. The tricuspid annulus is also related to the base of the aortic valve, the membranous interventricular septum, the right coronary artery, the fibrous body, and the lateral atrioventricular junction. The following are various techniques for the tricuspid valve repair: 

• Suture annuloplasty 
  • Kay described the first suture annuloplasty technique to treat secondary tricuspid regurgitation. In this technique, sutures are placed to completely exclude the posterior tricuspid leaflet and convert the valve into a bicuspid valve.[29] 
  • Another technique introduced by De Vega is suture annuloplasty, in which 2 parallel sutures are placed in a counterclockwise fashion, starting from posteroseptal commissure to anteroseptal commissure, around the tricuspid valve annulus and tied together, reducing annular diameter.[30] However, the problem with this technique is that sutures can cut through the myocardium— especially if it is fragile.
• Ring annuloplasty 
  • Carpentier introduced the technique of using a rigid or semi-rigid ring to reinforce and fixate the tricuspid annulus in systole to restore the physiological geometry of the tricuspid valve. The size of the ring is typically decided by measuring the distance from the anteroseptal commissure to the posteroseptal commissure.[31] The proximity of the conduction system and the aortic root requires careful suture placement during the procedure. 
  • A retrospective study published in 2004 by McCarthy et al examined 790 patients treated at the Cleveland clinic. The research evaluated the durability and risk factors associated with different techniques of tricuspid repair. According to the results, regurgitation remained stable with a rigid ring, increased gradually with a flexible band, and rose quickly over time with DeVega suture annuloplasty and pericardial strip reinforcement procedures. While the indications and techniques for tricuspid repair are still in their infancy, the current data suggest that repair with a rigid, near-complete ring is the best option.[32]
• Clover technique 
  • Alfieri proposed stitching together the leaflets' middle points (a concept similar to the Alfieri stitch for the mitral valve) and adding ring annuloplasty to decrease the annular diameter of the tricuspid valve. This technique gives the valve a clover shape, known as the clover technique, and has been used in primary and secondary tricuspid regurgitation.[33] 
• Other surgical techniques
  • Other surgical techniques for tricuspid valve repair are used in primary tricuspid regurgitation and depend on the mechanism and involved pathology. They range from surgical intervention and repair of leaflets when there is a prolapse or flail segment, chordal transposition or neochord when there is chordal rupture, and sliding papillary muscle repair when there is a diseased or elongated papillary muscle.[34] 
  • If the valve is primarily affected by a diseased process and a repair technique is not feasible to correct the pathology, such as carcinoid syndrome or endocarditis, valve replacement should be considered. Usually, a bioprosthetic valve is chosen for the tricuspid position due to decreased pressures, increased thrombotic risk, and future chances of pacemaker lead placement.
• Transcatheter repair 
  • Though it has been shown that untreated tricuspid regurgitation has adverse outcomes, most of the patients with sole tricuspid pathology still receive conservative treatment due to the high risk involved with the surgery. For this reason and because of the success of treating other valve problems, the percutaneous transcatheter tricuspid repair is gaining attention. Many innovative technologies are under investigation for transcatheter tricuspid valve repair targeting leaflet coaptation, annuloplasty, and prosthetic valve deployment. Currently, the most widely used technique is the off-label use of the edge-to-edge clip repair system.[35] Current surgical tricuspid annuloplasty consists of ring and suture techniques. Of suture techniques, the surgical plication of the posterior leaflet, making the valve functionally bicuspid, and the suturing of the 3 leaflets edge to edge are the most common techniques to treat severe tricuspid regurgitation. T-TEER can produce results similar to those of these suture techniques. Reports of the first cases of transcatheter tricuspid valve repair were published in 2016 in patients with severe tricuspid regurgitation and a high surgical risk of complications.[36] Intraprocedural guidance to direct the clip at the desired leaflets is a challenge in this technique due to the anteriorly located tricuspid valve and 3 leaflets.[15]
  • Three-dimensional transesophageal echocardiography is required to place the clips successfully. The other challenge is the steering of the clip system, as it is not designed to be used for the tricuspid valve. Percutaneous transcatheter tricuspid repair techniques can be broadly divided into the following categories:
    • Direct suture annuloplasty 
    • Direct ring annuloplasty
    • Coaptation enhancement
  • The inferior vena cava is very close to the tricuspid valve and septum, making it challenging to steer the system perpendicular to the valve for clip deployment.[37] The main aim is to deploy the clips to reduce the valve's effective regurgitation orifice area (EROA). Usually, deploying the valve on septal and anterior leaflets gives the best results.[38] Other techniques are deploying 2 clips on the septal anterior and septal posterior leaflets and a zipping technique, where 2 clips are deployed to the anteroseptal commissure, making the valve bicuspid. This technique is being used in patients considered high risk for surgery. Though there are no set criteria available so far to exclude patients for this procedure, patients with concurrent tricuspid stenosis, EROA more than 1.5 cm², coaptation defect more than 15 mm, and restricted leaflet mobility due to hardware like implanted leads, are considered not suitable for transcatheter repair.[39]
  • There are transcatheter annuloplasty devices under investigation for treating functional tricuspid regurgitation, where transcatheter direct annuloplasty can be performed by anchoring a ring whose size can be controlled according to the desired diameter.[40] In some cases, due to annular dilatation and leaflet involvement, a combined approach using a coaptation device along with an annuloplasty device is warranted for better results.[41]

Complications

The complications involved with tricuspid valve repair, whether surgical or transcutaneous, are generalized to any valvular procedure of the heart. The following complications can occur after tricuspid valve repair:

• Perioperative bleeding and resulting blood product transfusion-related complications
• Arrhythmias and heart blocks
• Heart failure
• Stroke
• Infections of the surgical site and/or the valve prosthesis
• Sepsis
• Pulmonary complications, eg, pneumonia, embolisms 
• Renal failure (higher risk in transcatheter procedures with pre-existing renal disease due to dye use)
• Drug reactions
• Prosthetic valve malfunction [25]

The tricuspid valve has been considered a "forgotten" valve due to hesitation in treating sole tricuspid lesions in the past. Surgical mortality for tricuspid valve replacement is 3 to 4 times higher compared to other single-valve open procedures. Severe tricuspid regurgitation is associated with a poor prognosis independent of age, biventricular function, and right ventricular size. Most tricuspid valve repair procedures are performed with the left-sided cardiac procedure.

The current gold standard for surgical repair is ring annuloplasty with an incomplete semirigid annuloplasty ring. Still, some centers perform modified bicuspidisation when the annulus is not severely dilated. As only a tiny fraction of patients are considered surgical candidates, there has been a renewed interest in developing percutaneous transcatheter devices for tricuspid regurgitation. Percutaneous techniques will likely increase due to improved technology and increased awareness of tricuspid regurgitation's effects on long-term outcomes.

Clinical Significance

Tricuspid valve repair as a sole procedure is relatively uncommon. Historically, tricuspid valve incompetence has not been considered significant to affect the outcome, a concept which is questioned in recent studies, showing untreated tricuspid regurgitation, particularly in the presence of other cardiac diseases, is associated with increased morbidity and mortality.[42] Moderate to severe tricuspid regurgitation should not be ignored, as it eventually affects the quality of life and survival. With more options available for tricuspid valve repair, surgical valvuloplasty, and percutaneous repair, any significant degree of tricuspid regurgitation should be addressed.

Enhancing Healthcare Team Outcomes

Effective tricuspid valve repair management requires clinical skills, strategic planning, interprofessional communication, and care coordination. Clinicians must develop procedural expertise in surgical or catheter-based repair techniques while accurately assessing patient suitability for intervention. Nurses play a vital role in perioperative care, including monitoring for complications, managing wound care, and educating patients about postoperative recovery. To improve patient safety and outcomes, pharmacists ensure optimal medication management, including anticoagulation and heart failure therapies. Each team member must apply evidence-based practices to support comprehensive, patient-centered care.

Interprofessional communication is crucial to synchronizing efforts among healthcare professionals. Regular case discussions, preoperative planning meetings, and post-procedure debriefings enhance team performance and facilitate the timely identification of potential complications. Care coordination ensures a seamless transition across care settings, from initial evaluation to postoperative follow-up. Collaborative strategies—such as creating individualized care plans, employing standardized protocols, and leveraging electronic health records for shared documentation—help optimize outcomes, reduce errors, and promote a culture of safety. This integrated approach ensures that all professionals contribute effectively to improving patient-centered outcomes in tricuspid valve repair.