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Canadian Journal of Cardiology

Tricuspid Regurgitation After Previous Left Heart Surgery: Are Transcatheter Approaches a Viable Solution?

      Although tricuspid regurgitation (TR) is a common finding, primary disease of the tricuspid valve (TV) is an uncommon lesion in developed countries.
      • Cohen SR
      • Sell JE
      • McIntosh CL
      • Clark RE
      Tricuspid regurgitation in patients with acquired, chronic, pure mitral regurgitation. I. Prevalence, diagnosis, and comparison of preoperative clinical and hemodynamic features in patients with and without tricuspid regurgitation.
      The more common “functional” TR, is a consequence of annular dilatation and distortion of the subvalvular apparatus, often resulting from right ventricular (RV) dilation and dysfunction.
      • Mascherbauer J
      • Maurer G
      The forgotten valve: lessons to be learned in tricuspid regurgitation.
      These features are most often driven by left heart disease, pulmonary hypertension, and atrial fibrillation. The unproven assumption that TR would improve or resolve when the left-sided lesion has been treated lead to a very conservative approach to anything less than severe TR.
      • Braunwald NS
      • Ross J
      • Morrow AG
      Conservative management of tricuspid regurgitation in patients undergoing mitral valve replacement.
      Furthermore, the excessive morbidity and mortality associated with TV surgeries supported this approach, although untreated significant TR itself carries a poor long-term prognosis.
      • Kilic A
      • Saha-Chaudhuri P
      • Rankin JS
      • Conte J V
      Trends and outcomes of tricuspid valve surgery in North America: an analysis of more than 50,000 patients from the Society of Thoracic Surgeons database.
      • Nath J
      • Foster E
      • Heidenreich PA
      Impact of tricuspid regurgitation on long-term survival.
      Evidence generated over the past 15 years has led to a more aggressive approach to tricuspid repair in patients undergoing left heart valvular surgery.
      • Dreyfus GD
      • Corbi PJ
      • Chan KM
      • Bahrami T
      Secondary tricuspid regurgitation or dilatation: which should be the criteria for surgical repair?.
      • Chan V
      • Burwash IG
      • Lam B
      • et al.
      Clinical and echocardiographic impact of functional tricuspid regurgitation repair at the time of mitral valve replacement.
      • Lee J
      • Song J
      • Park JP
      • et al.
      Long-term prognosis of isolated significant tricuspid regurgitation.
      In many instances of mitral regurgitation, particularly secondary to ischemic or nonischemic cardiomyopathy, the base disease might impair left and RV function progressing to significant tricuspid annular dilatation and leaflet tethering. Worsening of TR might continue despite correction of the mitral disease. Because this patient population is heterogeneous, disease progression is variable, being dependent on the baseline lesion, where early correction of degenerative mitral regurgitation shows the least TR progression.
      • Pozzoli A
      • Lapenna E
      • Vicentini L
      • Alfieri O
      • De Bonis M
      Surgical indication for functional tricuspid regurgitation at initial operation: judging from long term outcomes.
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