Functional Tricuspid Regurgitation Functional tricuspid regurgitation often occurs in patients with advanced mitral valve disease combined with pulmonary hypertension. After successful repair of the mitral valve or mitral valve replacement surgery, tricuspid regurgitation may disappear or improve significantly. However, secondary tricuspid regurgitation is now being treated more aggressively, and tricuspid annuloplasty is being performed in patients with dilated tricuspid annulus or more than mild tricuspid regurgitation. Rheumatic fever remains the most common cause of organic tricuspid valve disease, which is often combined with mitral and aortic valve disease, and often both tricuspid stenosis and regurgitation are present at the same time. Degenerative disease Degenerative tricuspid regurgitation is relatively uncommon, but in severe cases surgical repair is required. Bacterial endocarditis Bacterial endocarditis of the tricuspid valve is seen in patients with intravenous drug abuse, sometimes in patients with long-term placement of central venous lines, or occasionally in patients with small perimembranous septal defects. Infection often destroys tricuspid leaflet tissue, causing it to regurgitate. Medical causes of tricuspid insufficiency include tricuspid regurgitation from pacemaker electrodes and radiation therapy, which can cause contracture and calcification of the tricuspid leaflets. Carcinoid tumors often affect both the tricuspid valve and the pulmonary valve, resulting in stenosis and insufficiency of the valve. The controversy over the management of functional tricuspid regurgitation reflects the difficulty of accurately distinguishing between the two stages of the same disease, i.e., reversible and irreversible tricuspid regurgitation. Irreversible functional tricuspid regurgitation is the result of chronic right ventricular dilatation with permanent right ventricular volume increase and enlargement of the tricuspid annulus. Of course, if severe tricuspid regurgitation is present, there must be significant tricuspid valve pathology present, and it is most likely irreversible. However, even if tricuspid regurgitation is only mild or moderate, there may still be irreversible tricuspid valve pathology. This is because the estimate of the degree of tricuspid regurgitation depends on the preload and afterload of the right ventricle at the time of assessment. A better indicator of irreversible tricuspid valve lesions may be the size of the tricuspid annulus. If the distance from the anterior-septal to the anterior-posterior junction is measured directly via a right atrial incision and is greater than or equal to 70 mm (2 times the normal size), the tricuspid annulus is likely to fail to return to normal size and continue to enlarge. We recommend tricuspid valve repair for adult patients with a tricuspid annulus greater than 70 mm and moderate to severe tricuspid regurgitation. Surgical treatment Tricuspid valve suture annuloplasty (De Vega plication) The endocardium and fibrous annulus of the posterior-septal junction, posterior leaflet, anterior-posterior junction, anterior leaflet, and anterior-septal junction are sutured with sutures starting from the tricuspid annulus at the posterior-septal junction and running counterclockwise along the circumference of the tricuspid valve, in a 2-layer sequence of deep sutures. The sutures are tightened appropriately, and the tricuspid annulus is reduced to the appropriate size and then tied and secured. Tricuspid Annuloplasty Using a Forming Ring A variety of tricuspid annuloplasty rings are available, including partial forming rings and elastic forming strips. They conform to the normal tricuspid valve shape but do not include the septal annular region of the tricuspid valve. The tricuspid annuloplasty performed with a strip or ring reduces the size of the tricuspid orifice and restores the valve to its normal shape Tricuspid diaphysealization Using sutures, multiple figure-of-eight sutures are placed at the anterior-posterior and posterior-septal junctions of the tricuspid valve, often eliminating the entire posterior tricuspid annulus and turning the tricuspid valve into a diaphyseal valve. This annuloplasty technique reduces tricuspid regurgitation. Two sutures from the anterior-posterior junction to the posterior-septal junction are used to eliminate the posterior annulus. (a) Rheumatic tricuspid valve disease Rheumatic tricuspid valve lesions are usually a combination of mixed insufficiency and stenosis, which usually requires tricuspid valve replacement. Sometimes, tricuspid stenosis is the predominant lesion, with tricuspid junction fusion, leaflet thickening, and varying degrees of tendon fibrosis and shortening. This group of patients is suitable for valvular junction dissection. (b) Degenerative tricuspid valve disease Mucinous degenerative disease can affect the tricuspid valve and lead to tricuspid regurgitation. The anterior tricuspid valve leaflet is most commonly involved and undergoes prolapse or shackle-like changes due to tendon lengthening or rupture. If severe tricuspid regurgitation is still present after all repair methods have been tried, “edge-to-edge” surgery may be considered. This technique is particularly effective in patients with significant pulmonary hypertension. Several U-shaped sutures are made at the anterior, posterior, and septal leaflets at the midpoint of the opposing margins of the primary tendon attachments, and the three leaflets are sutured together to form a three-hole valve. The valve was tested with saline to check for residual leakage and valve deformation. Mild residual tricuspid regurgitation can be managed by adding an “edge-to-edge” suture at the junction of the adjacent leaflets. Measure all orifices with a Hegar dilator to confirm that there is sufficient total orifice area. (iii) Tricuspid regurgitation due to pacing leads Pacing leads placed in the endocardium can twist and become involved in one of the tricuspid leaflets, causing regurgitation. It is possible to reconstruct the tricuspid valve by removing the affected valve. Subsequently, the original pacing lead is removed and the epicardial ventricular pacing lead is repositioned. However, if the valve leaflets are extensively involved, valve replacement is required. (iv) Tricuspid valve endocarditis When antibiotic and antifungal therapy for tricuspid valve endocarditis is ineffective, the valve needs to be removed and valve replacement performed. However, if possible, it is important to preserve the valve itself. The bulge is usually large and attached to the leaflet tissue, and the infection often causes damage to the leaflet tissue and its attachment site. If the posterior tricuspid leaflet is involved, the area of necrosis and sufficient surrounding healthy tissue needs to be removed and then a valvuloplasty procedure performed. When the septal or anterior leaflets are involved, the lesion is removed in a trapezoidal fashion. A local annuloplasty is then performed with horizontal mattress sutures, followed by interrupted sutures to the edges of the incised leaflets. Removal and repair of the septal leaflets can result in complete heart block, so permanent epicardial pacing leads should be placed in these patients.