Tricuspid annuloplasty: Too many, too few? Virtue may be in the middle!

Significant secondary tricuspid regurgitation, often accompanied by right ventricular dilation and dysfunction, occurs in a significant proportion of patients submitted to surgery for severe mitral valve disease. It appears a vicious circle that is not interrupted by the treatment of the left heart valve alone, hence it requires concomitant intervention on the tricuspid valve.

In this commentary I will discuss a paper published in this issue of the Journal by Calafiore et al from Riyadh - Saudi Arabia, reporting a retrospective study that evaluated the influence of preoperative right ventricular and tricuspid valve (TV) remodeling on the fate of tricuspid annuloplasty (TA) and RV in 423 patients undergoing TA for functional TR operated on from May 2009 to December 2015 at their institution.

Current guidelines and other consensus documents recommend that tricuspid valve surgeryshould be considered (class IIa) in patients with mild/moderate secondary regurgitation and/or significant annular dilatation. However, rates of tricuspid annuloplasty performed during operations to left-heart valves are very variable, depending also on the etiology of the mitral disease.

Different methods of annuloplasty are used by the surgical community - suture, rings, bands - with widely variable results with regard to the recurrence of regurgitation and long-term survival. Not all these techniques are standardised and this may also be a cause for the disparate results.

In the absence of randomized studies, which are highly unlikely to be undertaken in this situation, more information is required from large series with longer follow-ups.