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Rationale of functional tricuspid annular dilatation based on standardized intraoperative measurements
Noriyasu Kawada1, Hirokuni Naganuma1, Koichi Muramatsu1
1Department of Cardiac Surgery, Jikei University School of Medicine Kashiwa Hospital, Kashiwa City, Chiba, Japan.
Objective:
Functional tricuspid regurgitation (FTR) is commonly attributed to annular dilatation; however, the segment-specific patterns and mechanisms of annular remodeling remain incompletely defined. This study aimed to characterize the segmental and mechanistic features of functional tricuspid annular dilatation using standardized intraoperative measurements.
Methods:
We retrospectively analyzed 106 patients who underwent tricuspid ring annuloplasty concomitant with left-sided valve surgery for FTR between April 2015 and October 2025. Tricuspid annular length was measured intraoperatively using standardized anatomic segmentation into septal, posterior, and anterior components. Patients were stratified by left ventricular diastolic diameter, tricuspid regurgitation pressure gradient, cardiac rhythm, and number of posterior leaflet scallops. Cadaveric annular measurements from a previous anatomic study served as controls.
Results:
Compared with cadaveric controls, patients with FTR demonstrated significant elongation of total and posterior annular lengths, whereas septal and anterior lengths were relatively preserved. Left ventricular diastolic diameter >56 mm was associated with enlargement of total and posterior annular lengths with minimal septal involvement. Tricuspid regurgitation pressure gradient was not associated with annular dimensions but correlated with greater severity of tricuspid regurgitation. Atrial fibrillation was associated with selective anterior annular enlargement. A greater number of posterior leaflet scallops was associated with disproportionate posterior annular elongation, indicating a leaflet-driven mechanism of posterior annular remodeling.
Conclusions:
Functional tricuspid annular dilatation is nonuniform and predominantly involves the posterior annulus. Ventricular, atrial, and valvular factors exert distinct, segment-specific effects on annular geometry, providing a structural and mechanistic rationale for individualized annuloplasty strategies.
