Nishimura, RA et al.

2014 AHA/ACC Valvular Heart Disease Guideline

8.2.3. Intervention

Class I

1. Tricuspid valve surgery is recommended for patients with severe TR (stages C and D) undergoing left-sided valve surgery. (Level of Evidence: C)

Class IIa

1. Tricuspid valve repair can be beneficial for patients with mild, moderate, or greater functional TR (stage B) at the time of left-sided valve surgery with either 1) tricuspid annular dilation or 2) prior evidence of right HF (237-246). (Level of Evidence: B)

2. Tricuspid valve surgery can be beneficial for patients with symptoms due to severe primary TR that are unresponsive to medical therapy (stage D). (Level of Evidence: C)

Class IIb

1. Tricuspid valve repair may be considered for patients with moderate functional TR (stage B) and pulmonary artery hypertension at the time of left-sided valve surgery. (Level of Evidence: C)

2. Tricuspid valve surgery may be considered for asymptomatic or minimally symptomatic patients with severe primary TR (stage C) and progressive degrees of moderate or greater RV dilation and/or systolic dysfunction. (Level of Evidence: C)

3. Reoperation for isolated tricuspid valve repair or replacement may be considered for persistent symptoms due to severe TR (stage D) in patients who have undergone previous left-sided valve surgery and who do not have severe pulmonary hypertension or significant RV systolic dysfunction. (Level of Evidence: C)

With respect to you, Ostroumov E N

Thanks for your answer.  "Tricuspid valve repair can be beneficial for patients with mild, moderate, or greater functional TR (stage B) at the time of left-sided valve surgery with either 1) tricuspid annular dilation or 2) prior evidence of right HF (237-246). (Level of Evidence: B)". This mean that pts with mild FTR and annulus dilatation should have tricuspid repair at the time of left-sided valve surgery to prevent those cases who will develop RV dysfunction and worsening of TR. The problem is when you have mild FTR and a not dilated annulus but a reduced systolic annulus shortening (dysfunction of periannular myocardium; also this situation may develop RV dysfunction in some cases ). For this reason I think that the evaluation of function is more useful than annulus dimension and degree of TR in decision making.

Obviously you're right. However, there is a significant relationship of both ventricles in diastole. Therefore it is necessary to consider the presence or lack of pulmonary arterial hypertension.

With respect to you, Ostroumov E N

I agree with you. Thanks.

TV REPAIR  FUNCTIONAL TR  IS INDICATED  IN PRESENCE ::

   SEVERE TR  BOTH IN STAGE C AND STAGE D   VALVULAR HEART DISEASE   AT THE TIME OF LEFT SIDED HEART SURGERY.

PROGRESSIVE  TR IN PRESENCE OF TRICUSPID ANNULAR DILATATION

Thanks dr Kariyappa, I agree with you. But what about those pts with mild not repaired regurgitation that develop after 1-3 years worsening of ventricular dysfunction and TR and heart failure?

Matsunaga et al  reported that ,34 of 70 patients undergoing mitral valve repair for functional ischemic mitral regurgitation, 30% of patients (21/70) had at least moderate TR before surgery. In the postoperative period, the prevalence of at least moderate TR increased over time, from 25% at 1 year, 53% at 1 to 3 years, and 74% at 3 years of follow-up.

. Dreyfus et al  reported   that at the time of mitral valve repair, the presence of tricuspid annular dilation (70 mm measured intraoperatively), even in the absence of significant  TR, should be an indication for tricuspid valve annuloplasty.  TR increased by at least 2 grades in 45% of the patients who received isolated mitral valve repair, supporting the notionthat tricuspid dilation is an ongoing, progressive process thatoften warrants preemptive surgical treatment.

Leftsided  heart failure with chamber enlargement and mitral regurgitation can result in right-sided pressure overload, right ventricular chamber enlargement, tricuspid annular dilation, and resultant TR. Tricuspid annuloplasty was performed selectively onlyon those patients whose tricuspid annular diameter (as measured

from the anteroseptal commissure to the anteroposterior commissure) was greater than twice the normal size(70 mm). In follow-up, TR grade (0.4 +/-0.6 versus

2.1+/-1.0, mitral valve repair plus tricuspid valve repair versus mitral valve repair alone, P0.001) and New York Heart Association class were significantly improved in those who underwent TV annuloplasty.

Studies imply that  ,tricuspid valve  annuloplasty  is tro be done in presence of annular dilatation in left sided failure.

Based on my experience in surgical treatment of functional tricuspid regurgitation, and according to a recent analysis that I performed on 527 consecutive patients (mean age: 69.6±9.5 years) with grade ≥1+ TR (graded from 0 to 3+)secondary to left-sided heart valve disease, I concluded that:

"Preoperative left ventricular ejection fraction 40 mm (p=0.001) and the use of DeVega annuloplasty (p=0.019) were predictors of grade ≥2+ TR at follow-up. There was a strong linkage between grade ≥2+ TR and new left-sided valvular lesions (odds ratio=5.3, 95% CI: 2.5–11; p

Annular dilatation in FTR is secondary to RV overload and then dysfunction. I do not know whether or not it is reversible or when it will decrease after left-sided valve surgery without TV repair; few argue about the importance or not of RV function situation in TV repair decision making, many argue on the entity of TR.  On the other hands, annular diameter is a good parameter  but its increase will remain fixed due to its unmodifiable structure; better in my opinion its % systolic shortening being a dynamic parameter. I think that TV annular and RV dysfunction if not evaluated and corrected (early and when it is possible) may give us not few surprises in the follow up of our patients. In our past experience that compared TV repair yes or not, we observed one month improvement in all; after 2-4 years, in pts without repair vs repair, about 40% of pts showed an increase of TR to mild to massive and in about half of them a new interventation was necessary. For this, we now suggest to consider also annular dynamic parameters and RV function information obtained with speckle tracking.

I agree with you. At my institution, according to recent Guidelines, in the presence of right heart dilation (tricuspid annular dilation), right ventricular dysfunction (right ventricular systo-diastolic fractional area change) and pulmonary hypertension, even mild functional TR is treated with annuloplasty device during every operation for left-sided heart valve disease . Thanks to this good (I think) practice, I have not a representative number of  patients with untreated significant TR. Thus, no comparative study could be performed. Since 2010, suture tricuspid annuloplasty is no more performed in Trieste.