Surgical approach to functional tricuspid regurgitation: should we be more aggressive?

Functional tricuspid regurgitation (FTR) is an important clinical entity that is encountered frequently during the operative management of left-sided heart valve disease, particularly in the setting of mitral regurgitation. Failure to recognize the importance of FTR during mitral valve surgery may result in inferior early and late outcomes because of the progression of tricuspid regurgitation and right heart failure. In this review, attention is focused on recent literature, which increasingly supports the use of corrective tricuspid valve annuloplasty, and the growing consensus that FTR or tricuspid annular dilation should be more aggressively addressed at the time of cardiac surgery.

The European Society of Cardiology and the European Association for Cardiothoracic Surgery (ESC/EACTS) 2012 guidelines recommend a more proactive approach to tricuspid regurgitation correction and highlight the shifting consensus toward more aggressive surgical therapy. Rigid annuloplasty rings should be used in favor of flexible bands or DeVega-style repairs. Preoperative determinants of clinical outcomes now include echocardiographic parameters of tricuspid valve tenting area, and associated right ventricular size and function.

Despite data demonstrating inferior outcomes in the presence of residual tricuspid regurgitation after cardiac surgery, surgical repair for FTR appears to be underutilized. Increased recognition and correction of tricuspid regurgitation at the time of surgery is increasingly supported by published guidelines, although randomized prospective data are needed to bolster current recommendations.