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Page 2 of 6 Nardi et al. Vessel Plus 2018;2:4 I http://dx.doi.org/10.20517/2574-1209.2017.35

We have reviewed the current guidelines and several reports for recommending tricuspid valve repair, also
in the light of our recent experience in the treatment of FTR. It is our opinion that a dysfunction of the
tricuspid valve even if in the early stages of manifestation, should be corrected at the time of concomitant
left-sided heart surgery, i.e., mitral valve surgery.

AMERICAN AND EUROPEAN GUIDELINES
The 2014 American Heart Association/American College of Cardiology guidelines indicate that surgery for
the treatment of FTR is required for patients affected by a severe degree of regurgitation (stages C and D
[12]
of the tricuspid valve disease) undergoing left-sided valve surgery . This type of indication is in Class I,
with Level C of evidence. Risks and benefits of tricuspid valve surgery should be carefully evaluated in the
presence of severe right ventricle systolic dysfunction or irreversible pulmonary hypertension, potentially
causing a right ventricle failure after operation. In Class IIa with Level B of evidence, it is recommended
the repair of FTR in the presence of mild or moderate tricuspid regurgitation (stage B of the tricuspid valve
disease) at the time of left-sided valve surgery either in the presence of tricuspid annular dilation or with
prior evidence of right heart failure. In Class IIb with Level C of evidence tricuspid valve repair may be
recommended in the presence of moderate FTR (stage B) and pulmonary artery hypertension at the time of
left-sided valve surgery. The 2017 European Society of Cardiology/European Association for Cardio-Thoracic
Surgery guidelines focus on the timing of surgical intervention based on the concept that surgery of the
tricuspid valve should be carried out sufficiently early to avoid late irreversible right ventricular dysfunction
or progression of FTR .
[13]
In presence of FTR, adding tricuspid valve repair, if indicated during left-sided surgery, not only does not
increase the operative risk, but also has been demonstrated to provide reverse remodeling of the right
ventricle and to improve the functional status. The indication with Level C of evidence in Class I, IIa, IIb are
similar to those reported by the American guidelines, with the exception of Class IIb, where it is stated that
surgery may be considered in patients with mild or moderate FTR, even in the absence of annular dilatation,
when previous right heart failure has been documented. In both American and European Guidelines the
annulus dilatation of the tricuspid valve defined as greater than 40 mm or 21 mm/m by 2D echocardiography
2
2
represents a surgical indication for the treatment. In fact, a diastolic diameter greater than 40 mm or 21 mm/m
increases the risk of persistent or progressive FTR after isolated mitral valve surgery.

TRICUSPID VALVE REPAIR TECHNIQUES
[14]
Repair techniques for the treatment of FTR have been introduced by Kay et al. in 1965 and De Vega
[15]
in 1972. Kay’s technique provides the obliteration of the posterior tricuspid leaflet by placement of several
sutures across the posterior segment of the tricuspid valve annulus making the valve as bicuspid. De Vega’s
technique provides the annuloplasty by placement of two semicircular sutures around the annulus anchored
with two pledgets (2-0 Ti-cron), starting from the anterior-septal commissure and ending in front of the
origin of the coronary sinus.

Ring annuloplasty, first introduced by Carpentier et al. in 1974, is thought to offer the best long-term
[2]
outcomes for severe FTR, by means of a more complete annular stabilization. However, this procedure leads
to prolongation of the operation and cardiopulmonary bypass time. Therefore intervening on moderate
functional TR in the context of another cardiac procedure may become a decision-making dilemma.

CURRENT EARLY AND LATE RESULTS OF THE REPAIR TECHNIQUES
Marquis-Gravel et al. examined the outcomes of 926 cases of tricuspid valve surgery performed over a 30-
[16]
year period. Of them, 792 patients underwent tricuspid valve repair (85%) more frequently in concomitance