Expanding the Surgical Indications for Functional Tricuspid Valve Regurgitation

10.1055/a-2300-6791

In response to Kaneyuki et al's appropriate invitation to conduct further research on the surgical indications for tricuspid valve (TV) surgery alongside left-sided valve procedures, we present some pathophysiological observations, based mainly on our experience with mitral valve (MV) repair.[1] This procedure usually eliminates one of the key factors responsible for progressive pulmonary artery hypertension. In fact, left atrial hypertension proportionally increases postcapillary resistance and mainly that of the precapillary arterioles, where the predominant elastic component is replaced by smooth muscle cells, subsequently undergoing fibrotic changes. At the same time, according to the Frank–Starling law, right ventricle (RV) overload, secondary to TV regurgitation, leads to progressive ventricular wall hypertrophy and subsequent dilation, functionally more challenging. This is often followed by lateral displacement of the chordae tendineae and papillary muscles, further enlarging the tricuspid annulus.[2] A similar effect may occur after mitral valve repair performed with a rigid annuloplasty ring, which stiffens the atrioventricular plane, allowing the forces generated by left ventricle (LV) systole to escape anteriorly and medially and further widen the tricuspid valve ring. Therefore, progressively more severe TV regurgitation causes RV overload and subsequent dilation, which can lead to a ‘RV-driven’ heart failure. Today, 3D Echocardiography and 4D cardiac magnetic resonance imaging can be used to assess progressive degrees of TV regurgitation severity, even after left-sided valve repair.[3] Therefore, when scheduling a left-sided valve repair, typically concerning the MV, it is crucial to avoid the risk of underestimating a severe TV insufficiency, as this will be detected later, at the stage of irreversible RV dysfunction, with persistent ventricular overload and high energy dispersion. This is why there are such significant perioperative risks and poor functional results in cases of delayed TV repair.[1] Today, data obtained from preoperative cardiac hemodynamic studies can be used to predict the benefits of combined tricuspid valve (TV) and mitral valve (MV) repair. This can eventually be achieved through a preoperative virtual surgery procedure, implemented using artificial intelligence algorithms.

Publication History

Received: 08 October 2025

Accepted: 15 October 2025

Accepted Manuscript online:
22 October 2025

Article published online:
12 November 2025

• References

• 1 Kaneyuki D, Jordan AM, Rosen JL, Macmillan TR, Morris RJ, Tchantchaleishvili V. Isolated tricuspid valve surgery for functional tricuspid regurgitation. Thorac Cardiovasc Surg 2025; 73 (02) 111-116
• 2 Davidson LJ, Tang GHL, Ho EC. et al; American Heart Association Interventional Committee of the Council on Clinical Cardiology; Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation; Council on Cardiovascular Surgery and Anesthesia; and Council on Cardiovascular and Stroke Nursing. The tricuspid valve: a review of pathology, imaging, and current treatment options: a scientific statement from the American Heart Association. Circulation 2024; 149 (22) e1223-e1238
• 3 Pype LL, Domenech-Ximenos B, Paelinck BP, Sturkenboom N, Van De Heyning CM. Assessment of tricuspid regurgitation by cardiac magnetic resonance imaging: current role and future applications. J Clin Med 2024; 13 (15) 4481