Functional tricuspid regurgitation: indications, techniques, and outcomes

  • Tessa M. F. Watt
  • Alexander A. Brescia
  • Aaron M. Williams
  • Steven F. BollingEmail author
Original Article


Functional tricuspid regurgitation (TR) results from asymmetric dilation of the tricuspid valve annulus. This often occurs due to right ventricular enlargement and dysfunction as a consequence of myocardial or valvular abnormalities of the left heart. Even mild TR at the time of left-sided valvular surgery may worsen postoperatively, which carries poor prognostic implications. In spite of data revealing poor outcomes associated with residual TR, surgery for functional TR remains underutilized. Surgical repair techniques for TR include placement of a rigid or semi-rigid tricuspid annular ring, which has been shown to provide superior longevity compared with suture and flexible band repair techniques. Additionally, emerging percutaneous annuloplasty techniques to correct functional TR can expand interventional treatment options to patients who would otherwise carry prohibitive operative risk.


Functional tricuspid regurgitation Tricuspid repair Tricuspid annuloplasty Tricuspid rings 


Funding information

Alexander Brescia is supported by the National Research Service Award postdoctoral fellowship (No. 5T32HL076123).

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Research involving human participants and/or animals

Not applicable (N/A). There were no human participants or animal involvement.

Informed consent

Not applicable.


  1. 1.
    Rogers JH, Bolling SF. The tricuspid valve: current perspective and evolving management of tricuspid regurgitation. Circulation. 2009;119:2718–25.PubMedGoogle Scholar
  2. 2.
    Raja SG, Dreyfus GD. Surgery for functional tricuspid regurgitation: current techniques, outcomes and emerging concepts. Expert Rev Cardiovasc Ther. 2009;7:73–84.PubMedGoogle Scholar
  3. 3.
    Huffman LC, Nelson JS, Lehman AN, Krajacic MC, Bolling SF. Identical tricuspid ring sizing in simultaneous functional tricuspid and mitral valve repair: a simple and effective strategy. J Thorac Cardiovasc Surg. 2014;147:611–4.PubMedGoogle Scholar
  4. 4.
    Nath J, Foster E, Heidenreich PA. Impact of tricuspid regurgitation on long-term survival. J Am Coll Cardiol. 2004;43:405–9.PubMedGoogle Scholar
  5. 5.
    Benedetto U, Melina G, Angeloni E, et al. Prophylactic tricuspid annuloplasty in patients with dilated tricuspid annulus undergoing mitral valve surgery. J Thorac Cardiovasc Surg. 2012;143:632–8.PubMedGoogle Scholar
  6. 6.
    Singh SK, Tang GH, Maganti MD, et al. Midterm outcomes of tricuspid valve repair versus replacement for organic tricuspid disease. Ann Thorac Surg. 2006;82:1735–41.PubMedGoogle Scholar
  7. 7.
    Bernal JM, Morales D, Revuelta C, Llorca J, Gutiérrez-Morlote J, Revuelta JM. Reoperations after tricuspid valve repair. J Thorac Cardiovasc Surg. 2005;130:498–503.PubMedGoogle Scholar
  8. 8.
    Silver MD, Lam JH, Ranganathan N, Wigle ED. Morphology of the human tricuspid valve. Circulation. 1971;43:333–48.PubMedGoogle Scholar
  9. 9.
    Fukuda S, Saracino G, Matsumura Y, et al. Three-dimensional geometry of the tricuspid annulus in healthy subjects and in patients with functional tricuspid regurgitation: a real-time, 3-dimensional echocardiographic study. Circulation. 2006;114:I492–8.PubMedGoogle Scholar
  10. 10.
    Tei C, Pilgrim JP, Shah PM, Ormiston JA, Wong M. The tricuspid valve annulus: study of size and motion in normal subjects and in patients with tricuspid regurgitation. Circulation. 1982;66:665–71.PubMedGoogle Scholar
  11. 11.
    Deloche A, Guerinon J, Fabiani JN, et al. Anatomical study of rheumatic tricuspid valve diseases: application to the study of various valvuloplasties. Ann Chir Thorac Cardiovasc. 1973;12:343–9.PubMedGoogle Scholar
  12. 12.
    Ewy G. Valvular heart disease. Philadelphia: Lipincott Williams & Wilkins; 2000.Google Scholar
  13. 13.
    Antunes MJ, Rodríguez-Palomares J, Prendergast B, et al. Management of tricuspid valve regurgitation: position statement of the European Society of Cardiology Working Groups of Cardiovascular Surgery and Valvular Heart Disease. Eur J Cardiothorac Surg. 2017;52:1022–30.PubMedGoogle Scholar
  14. 14.
    Zoghbi WA, Adams D, Bonow RO, et al. Recommendations for noninvasive evaluation of native valvular regurgitation: a report from the American Society of Echocardiography developed in collaboration with the Society for Cardiovascular Magnetic Resonance. J Am Soc Echocardiogr. 2017;30:303–71.Google Scholar
  15. 15.
    Dreyfus J, Durand-Viel G, Raffoul R, et al. Comparison of 2-dimensional, 3-dimensional, and surgical measurements of the tricuspid annulus size: clinical implications. Circ Cardiovasc Imaging. 2015;8:e003241.PubMedGoogle Scholar
  16. 16.
    Hahn RT. State-of-the-art review of echocardiographic imaging in the evaluation and treatment of functional tricuspid regurgitation. Circ Cardiovasc Imaging. 2016;9:e005332.PubMedGoogle Scholar
  17. 17.
    Dreyfus GD, Corbi PJ, Chan KM, Bahrami T. Secondary tricuspid regurgitation or dilatation: which should be the criteria for surgical repair? Ann Thorac Surg. 2005;79:127–32.PubMedGoogle Scholar
  18. 18.
    Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014;63:2438–88.PubMedGoogle Scholar
  19. 19.
    Baumgartner H, Falk V, Bax JJ, et al. 2017 ESC/EACTS guidelines for the management of valvular heart disease. Rev Esp Cardiol (Engl Ed). 2018;71:110.Google Scholar
  20. 20.
    Gammie JS, O'Brien SM, Griffith BP, Ferguson TB, Peterson ED. Influence of hospital procedural volume on care process and mortality for patients undergoing elective surgery for mitral regurgitation. Circulation. 2007;115:881–7.PubMedGoogle Scholar
  21. 21.
    David TE, David CM, Fan CS, Manlhiot C. Tricuspid regurgitation is uncommon after mitral valve repair for degenerative diseases. J Thorac Cardiovasc Surg. 2017;154:110–22 e1.PubMedGoogle Scholar
  22. 22.
    Chikwe J, Itagaki S, Anyanwu A, Adams DH. Impact of concomitant tricuspid annuloplasty on tricuspid regurgitation, right ventricular function, and pulmonary artery hypertension after repair of mitral valve prolapse. J Am Coll Cardiol. 2015;65:1931–8.PubMedGoogle Scholar
  23. 23.
    Badhwar V, Rankin JS, He M, et al. Performing concomitant tricuspid valve repair at the time of mitral valve operations is not associated with increased operative mortality. Ann Thorac Surg. 2017;103:587–93.PubMedGoogle Scholar
  24. 24.
    Rivera R, Duran E, Ajuria M. Carpentier’s flexible ring versus De Vega’s annuloplasty. A prospective randomized study. J Thorac Cardiovasc Surg. 1985;89:196–203.PubMedGoogle Scholar
  25. 25.
    Tang GH, David TE, Singh SK, Maganti MD, Armstrong S, Borger MA. Tricuspid valve repair with an annuloplasty ring results in improved long-term outcomes. Circulation. 2006;114:I577–81.PubMedGoogle Scholar
  26. 26.
    McCarthy PM, Bhudia SK, Rajeswaran J, et al. Tricuspid valve repair: durability and risk factors for failure. J Thorac Cardiovasc Surg. 2004;127:674–85.PubMedGoogle Scholar
  27. 27.
    Navia JL, Nowicki ER, Blackstone EH, et al. Surgical management of secondary tricuspid valve regurgitation: annulus, commissure, or leaflet procedure? J Thorac Cardiovasc Surg. 2010;139:1473–82 e5.PubMedGoogle Scholar
  28. 28.
    Watt TMF, Brescia AA, Murray SL, et al. Degenerative mitral valve repair restores life expectancy. Ann Thorac Surg. 2019.
  29. 29.
    Bernal JM, Pontón A, Diaz B, et al. Surgery for rheumatic tricuspid valve disease: a 30-year experience. J Thorac Cardiovasc Surg. 2008;136:476–81.PubMedGoogle Scholar
  30. 30.
    Sarralde JA, Bernal JM, Llorca J, et al. Repair of rheumatic tricuspid valve disease: predictors of very long-term mortality and reoperation. Ann Thorac Surg. 2010;90:503–8.PubMedGoogle Scholar
  31. 31.
    Fukuda S, Gillinov AM, McCarthy PM, et al. Determinants of recurrent or residual functional tricuspid regurgitation after tricuspid annuloplasty. Circulation. 2006;114:I582–7.PubMedGoogle Scholar
  32. 32.
    Belluschi I, Del Forno B, Lapenna E, et al. Surgical techniques for tricuspid valve disease. Front Cardiovasc Med. 2018;5:118.PubMedPubMedCentralGoogle Scholar
  33. 33.
    Desai RR, Vargas Abello LM, Klein AL, et al. Tricuspid regurgitation and right ventricular function after mitral valve surgery with or without concomitant tricuspid valve procedure. J Thorac Cardiovasc Surg. 2013;146:1126–1132.e10.PubMedGoogle Scholar
  34. 34.
    Bertrand PB, Koppers G, Verbrugge FH, et al. Tricuspid annuloplasty concomitant with mitral valve surgery: effects on right ventricular remodeling. J Thorac Cardiovasc Surg. 2014;147:1256–64.PubMedGoogle Scholar
  35. 35.
    Castedo E, Cañas A, Cabo RA, Burgos R, Ugarte J. Edge-to-edge tricuspid repair for redeveloped valve incompetence after DeVega's annuloplasty. Ann Thorac Surg. 2003;75:605–6.PubMedGoogle Scholar
  36. 36.
    Castedo E, Monguio E, Cabo RA, Ugarte J. Edge-to-edge technique for correction of tricuspid valve regurgitation due to complex lesions. Eur J Cardiothorac Surg. 2005;27:933–4.PubMedGoogle Scholar
  37. 37.
    Lapenna E, De Bonis M, Verzini A, et al. The clover technique for the treatment of complex tricuspid valve insufficiency: midterm clinical and echocardiographic results in 66 patients. Eur J Cardiothorac Surg. 2010;37:1297–303.PubMedGoogle Scholar
  38. 38.
    Lohchab SS, Chahal AK, Agrawal N. Papillary muscle approximation to septum for functional tricuspid regurgitation. Asian Cardiovasc Thorac Ann. 2015;23:747–50.PubMedGoogle Scholar
  39. 39.
    Kypson AP, Glower DD. Minimally invasive tricuspid operation using port access. Ann Thorac Surg. 2002;74:43–5.PubMedGoogle Scholar
  40. 40.
    Lee TC, Desai B, Glower DD. Results of 141 consecutive minimally invasive tricuspid valve operations: an 11-year experience. Ann Thorac Surg. 2009;88:1845–50.PubMedGoogle Scholar
  41. 41.
    Wang Q, Xue X, Yang J, et al. Right mini-thoracotomy approach reduces hospital stay and transfusion of mitral or tricuspid valve reoperation with non-inferior efficacy: evidence from propensity-matched study. J Thorac Dis. 2018;10:4789–800.PubMedPubMedCentralGoogle Scholar
  42. 42.
    Gafoor S, Petrescu OM, Lehr EJ, et al. Percutaneous tricuspid valve regurgitation repair with the MitraClip device using an edge-to-edge bicuspidization technique. J Invasive Cardiol. 2017;29:E30–6.PubMedGoogle Scholar
  43. 43.
    Rodés-Cabau J, Hahn RT, Latib A, et al. Transcatheter therapies for treating tricuspid regurgitation. J Am Coll Cardiol. 2016;67:1829–45.PubMedGoogle Scholar
  44. 44.
    Hammerstingl C, Schueler R, Malasa M, Werner N, Nickenig G. Transcatheter treatment of severe tricuspid regurgitation with the MitraClip system. Eur Heart J. 2016;37:849–53.PubMedGoogle Scholar
  45. 45.
    Kowalski M, Franz N, Ritter F, et al. Simultaneous transfemoral transcatheter mitral and tricuspid valve edge-to-edge repair (using MitraClip system) completed by atrial septal defect occlusion in a surgically inoperable patient. First-in-human report. Kardiochir Torakochirurgia Pol. 2015;12:295–7.PubMedPubMedCentralGoogle Scholar
  46. 46.
    Van Praet KM, Stamm C, Starck CT, et al. An overview of surgical treatment modalities and emerging transcatheter interventions in the management of tricuspid valve regurgitation. Expert Rev Cardiovasc Ther. 2018;16:75–89.PubMedGoogle Scholar
  47. 47.
    Webb JG, Wood DA, Ye J, et al. Transcatheter valve-in-valve implantation for failed bioprosthetic heart valves. Circulation. 2010;121:1848–57.PubMedGoogle Scholar
  48. 48.
    Roberts P, Spina R, Vallely M, Wilson M, Bailey B, Celermajer DS. Percutaneous tricuspid valve replacement for a stenosed bioprosthesis. Circ Cardiovasc Interv. 2010;3:e14–5.PubMedGoogle Scholar
  49. 49.
    Kuwata S, Taramasso M, Nietlispach F, Maisano F. Transcatheter tricuspid valve repair toward a surgical standard: first-in-man report of direct annuloplasty with a cardioband device to treat severe functional tricuspid regurgitation. Eur Heart J. 2017;38:1261.PubMedGoogle Scholar
  50. 50.
    Schueler R, Hammerstingl C, Werner N, Nickenig G. Interventional direct annuloplasty for functional tricuspid regurgitation. JACC Cardiovasc Interv. 2017;10:415–6.PubMedGoogle Scholar
  51. 51.
    Rogers T, Ratnayaka K, Sonmez M, et al. Transatrial intrapericardial tricuspid annuloplasty. JACC Cardiovasc Interv. 2015;8:483–91.PubMedPubMedCentralGoogle Scholar

Copyright information

© Indian Association of Cardiovascular-Thoracic Surgeons 2020

Authors and Affiliations

  1. 1.Department of Cardiac SurgeryUniversity of Michigan, Frankel Cardiovascular CenterAnn ArborUSA

Personalised recommendations