Types of Tricuspid Valve Surgery

Introduction

The tricuspid valve is one of the four heart valves and plays a crucial role in regulating blood flow between the right atrium and the right ventricle. It ensures that blood flows in one direction from the right atrium to the right ventricle—and prevents backflow when the ventricle contracts. However, various conditions such as tricuspid regurgitation (leakage), tricuspid stenosis (narrowing), or a combination of both can impair the function of this valve. When medications and non-surgical treatments are no longer effective, tricuspid valve surgery becomes necessary to restore proper heart function.

Surgical treatment of the tricuspid valve has evolved over the years and now includes multiple approaches, each tailored to the severity of the disease, the underlying cause, and the overall health of the patient. In many cases, tricuspid valve disease coexists with other cardiac conditions, such as mitral or aortic valve disease, and may be addressed during combined surgical procedures. In other instances, isolated tricuspid valve surgery is performed, particularly when the disease has advanced or is causing significant symptoms such as fatigue, swelling, or liver congestion.

The different types of tricuspid valve surgery, discussing how each is performed and in what circumstances they are recommended. Understanding the types of surgery available empowers patients to make informed decisions alongside their healthcare teams.

Types of Tricuspid Valve Surgery

1. Tricuspid Valve Repair :- This is often the preferred surgical approach, especially in cases of tricuspid regurgitation where the valve structure remains largely intact but has become dilated or loose. During repair, the surgeon may perform an annuloplasty, which involves implanting a ring or band around the valve’s annulus (opening) to tighten it and restore its proper shape. Other techniques include reshaping or reinforcing the valve leaflets or adjusting the chordae tendineae and papillary muscles. Repair is particularly beneficial because it preserves the patient’s native tissue, reduces the risk of prosthetic-related complications, and eliminates the need for long-term blood thinners. Tricuspid valve repair is frequently performed alongside mitral valve surgery, as tricuspid regurgitation often coexists with left-sided valve disease. The long-term durability of repair depends on the underlying pathology and the precision of surgical technique.
2. Tricuspid Valve Replacement :- When the valve is severely damaged or the anatomy is not suitable for repair, replacement becomes necessary. In this procedure, the surgeon removes the damaged tricuspid valve and replaces it with either a mechanical valve or a biological (tissue) valve. Mechanical valves are durable and designed to last for decades, but they require lifelong anticoagulation therapy to prevent blood clots. Biological valves, derived from animal tissue, do not require long-term blood thinners but tend to have a shorter lifespan, especially in younger patients. Tricuspid valve replacement is generally considered when repair attempts have failed or are not technically feasible. It may also be the preferred option in cases of rheumatic disease, carcinoid syndrome, or infective endocarditis where the valve has been irreversibly damaged. Though effective, valve replacement carries higher risks of complications such as valve thrombosis or prosthesis dysfunction, and patients require careful postoperative monitoring.
3. Minimally Invasive Tricuspid Valve Surgery :- Minimally invasive approaches involve performing the valve procedure through small incisions, usually between the ribs on the right side of the chest, rather than opening the sternum. Specialized instruments and video-assisted technologies allow surgeons to operate with precision in a confined space. Minimally invasive tricuspid valve surgery can be used for both repairs and replacements and is associated with reduced trauma, less pain, quicker recovery, and shorter hospital stays. This approach is most suitable for selected patients without extensive disease or multiple comorbidities. While not universally applicable, minimally invasive techniques are gaining popularity and are particularly valuable in isolated tricuspid valve surgeries or reoperations.
4. Transcatheter Tricuspid Valve Repair :- For patients who are not candidates for open-heart surgery due to age or comorbid conditions, transcatheter tricuspid valve repair offers a less invasive option. In this procedure, a catheter is inserted usually via the femoral vein and advanced to the tricuspid valve under imaging guidance. Devices such as the TriClip or PASCAL system are used to grasp and approximate the valve leaflets, reducing the degree of regurgitation. This method resembles the MitraClip procedure used for mitral valve repair and is still under active clinical research. Though not yet widely available, transcatheter tricuspid repair shows promise for treating functional tricuspid regurgitation in high-risk patients. It offers symptom relief and quality-of-life improvement with fewer procedural risks compared to surgery.
5. Transcatheter Tricuspid Valve Replacement :- Similar to transcatheter repair, this method involves delivering a replacement valve to the tricuspid position using a catheter-based technique. The valve may be deployed directly into a failing bioprosthetic valve (valve-in-valve) or into the native valve (in investigational cases). TTVR is an emerging technology with growing interest, particularly for patients with failed surgical valves or those who are poor surgical candidates. Although early outcomes are promising, long-term durability and patient selection criteria are still being evaluated. As technology advances, TTVR may become a key component of tricuspid valve management in the future.
6. Hybrid Tricuspid Valve Procedures :- In complex cases where patients require more than one type of intervention or where anatomy poses unique challenges, hybrid procedures may be used. These combine open surgical and catheter-based techniques, allowing for maximum flexibility and customization. For example, a patient undergoing mitral valve surgery may receive a transcatheter device for tricuspid repair during the same procedure. Hybrid strategies aim to optimize outcomes while minimizing the overall burden of treatment. These are typically performed at specialized heart centers with expertise in both surgical and interventional cardiology.
7. Redo Tricuspid Valve Surgery :- In patients with previously implanted tricuspid valves especially biological prostheses valve dysfunction can occur over time, necessitating reoperation. Redo tricuspid surgery is inherently more complex due to scar tissue, altered anatomy, and increased procedural risks. However, with modern surgical planning, imaging, and perioperative care, repeat surgeries can be performed with good results. In some instances, valve-in-valve transcatheter approaches may be preferred to avoid the need for another open surgery.

Conclusion

Tricuspid valve surgery encompasses a broad range of techniques, each designed to restore valve function, relieve symptoms, and improve heart health. From traditional open repairs and replacements to innovative catheter-based interventions, the field of tricuspid valve therapy has made remarkable strides in recent years. The choice of surgical method depends on various factors, including the type and severity of the valve disease, patient age, comorbidities, and prior surgical history.

While valve repair is often preferred for preserving natural tissue and reducing complications, valve replacement remains a vital option when damage is severe or irreparable. Minimally invasive and transcatheter techniques are revolutionizing the treatment landscape by offering effective solutions for high-risk patients who would otherwise be ineligible for surgery. As research progresses and newer devices become available, treatment strategies will continue to evolve, offering safer and more personalized care.

Ultimately, successful tricuspid valve surgery hinges on accurate diagnosis, comprehensive evaluation, and a collaborative approach between cardiac surgeons, interventional cardiologists, and imaging specialists. With the right treatment, patients can look forward to a significant improvement in symptoms, heart function, and quality of life.