Causes and Management of Severe Tricuspid Regurgitation After Mitral Valve Repair

Primary Mechanisms

Severe tricuspid regurgitation (TR) and right ventricular (RV) enlargement following mitral valve repair most commonly result from untreated pre-existing functional TR that progresses due to persistent RV remodeling, even after correction of the left-sided valve lesion, as reported by the European Heart Journal 1, 2
Tricuspid annular dilation, even mild-to-moderate TR with annular dilation (≥40 mm or >21 mm/m²) at the time of mitral surgery, can progress to severe TR if left untreated, according to the European Heart Journal and the Journal of the American College of Cardiology 3, 4
Right ventricular remodeling and dysfunction, persistent RV dysfunction following mitral valve repair, can lead to progressive TR due to ongoing ventricular dilation and geometric changes, as noted by the European Heart Journal 5, 3
Pulmonary hypertension, residual pulmonary hypertension after mitral valve repair, can contribute to RV pressure overload, leading to RV dilation and functional TR, as reported by the European Heart Journal 2, 5
Pacemaker leads, transvenous pacemaker leads crossing the tricuspid valve, can contribute to TR progression, according to the European Heart Journal and the Journal of the American College of Cardiology 3, 4

Initial RV pressure/volume overload caused by mitral valve disease leads to RV dilation, as reported by the European Heart Journal 1, 6
Tricuspid annular dilation results from RV enlargement, causing leaflet tethering and reduced coaptation, according to the European Heart Journal 5, 3
Progressive TR creates a vicious cycle of further RV volume overload, dilation, and worsening TR, as noted by the European Heart Journal 5

Concomitant tricuspid repair should be performed during initial mitral valve surgery when severe TR is present, as recommended by the European Heart Journal and the Journal of the American College of Cardiology 1, 4
Concomitant tricuspid repair should also be performed when moderate TR is present, or even mild TR with annular dilation ≥40 mm or >21 mm/m², according to the European Heart Journal and the Journal of the American College of Cardiology 3, 4
Ring annuloplasty is the preferred technique for tricuspid repair, with better long-term results than suture annuloplasty, as reported by the European Heart Journal 5, 3
Early intervention is crucial to address TR before RV dysfunction becomes irreversible, as noted by the European Heart Journal 5, 3

Medical therapy, including diuretics, can be useful for patients with severe TR and signs of right-sided heart failure, according to the Journal of the American College of Cardiology 4, 7
Reoperation considerations, reoperation for isolated TR after previous mitral valve surgery, carries high risk and should be considered before severe RV dysfunction develops, as reported by the Journal of the American College of Cardiology 4, 7
The American College of Cardiology recommends early identification of RV dysfunction through echocardiography, evaluating contractility, dilation, and pulmonary pressures 8

The European Society of Cardiology recommends concomitant tricuspid annuloplasty when there is any tricuspid regurgitation with tricuspid annular dilation ≥40 mm or >21 mm/m², even if the tricuspid regurgitation appears mild, to prevent predictable progression 9
Mitral regurgitation can mask the severity of other valvular lesions due to altered loading conditions and flow dynamics, making comprehensive pre-operative assessment crucial 9, 10

In the presence of significant mitral regurgitation, tricuspid regurgitation severity is commonly underestimated due to decreased left ventricular preload and dynamic changes in pulmonary pressures, highlighting the need for accurate pre-operative assessment 9
The tricuspid annular diameter should have been measured, and if it was ≥40 mm or >21 mm/m², concomitant tricuspid annuloplasty was indicated regardless of apparent tricuspid regurgitation severity, according to the European Heart Journal 9

Reoperation for isolated tricuspid regurgitation after previous mitral surgery carries high operative risk and has poor long-term outcomes, emphasizing the importance of addressing tricuspid regurgitation during initial mitral surgery 11
Severe aortic regurgitation requires its own surgical evaluation independent of the mitral repair, with timing of intervention depending on symptoms, left ventricular dimensions, and left ventricular function per standard aortic regurgitation guidelines 10, 12
Ring annuloplasty is the preferred technique for tricuspid intervention, with better long-term outcomes compared to suture annuloplasty, as reported in the European Heart Journal 11