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The tricuspid valve

Valvular Heart Diseases

The forgotten valve

Tricuspid valve regurgitation (TR) occurs in approximately one third of patients with other cardiac valve disease, especially mitral disease. The co-existence of TR is a significant prognostic factor after surgery for left heart valve disease, if it is not corrected. Yet, only about 10% of patients have treatment for the tricuspid valve. Hence, a first appeal for the surgeons, as well as the cardiologists, to pay more attention to the tricuspid valve. Otherwise, late appearing TR will severely compromise survival.

Organic tricuspid valve disease is rarer and is usually of rheumatic origin, although other pathologies may be associated.

By contrast with mitral regurgitation, the diagnosis of the severity of TR is rather difficult. TR is associated with variable degrees of right ventricular (RV) dysfunction which is also particularly difficult to assess. This session included three talks on assessment of TR and RV function. Echocardiography remains the main tool but is not as accurate to identify the morphology of the tricuspid leaflets as with the mitral valve. 3-D echo has recently emerged as a better method for assessment of valve morphology and, although its definition still leaves a lot of room for improvement, it appears to be especially useful in the tricuspid valve.

On the other hand, magnetic resonance (MR) is a useful tool to assess RV function. Although not as easily available as echocardiography, it is particularly suited for analysis of blood flows, which also permits a more accurate assessment of the regurgitant fraction. From the surgical point of view, it may also be helpful in indicating the special relationship of the RV to the sternum in the case of re-operation.
Therefore, it remains a challenge to decide which patients require intervention on the tricuspid valve. Traditionally it was thought that by resolution of the left side valve pathology, “functional” TR would regress, but this does not always happen. Hence, it is current belief that moderate or severe TR should be addressed during surgery of the mitral (and/or aortic) valve. Late appearing TR, even in the presence of normal left side valves, should also be treated surgically before severe RV dysfunction ensues.

Tricuspid valve replacement is very rarely required, except for severe organic disease. Annuloplasty techniques can successfully correct TR in the vast majority of cases. Annuloplasty can be performed either with rings or bands or by annular sutures, such as the Kay and the DeVega techniques. Some works suggest that rings achieve better long-term results but this is not consensual. My own experience with a modified DeVega technique demonstrated good and durable results.

The key take-home message is:

Please do not forget the tricuspid valve in your assessment and management of left side valve pathology.




The tricuspid valve

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.