Nov. 18, 2025
Mayo Clinic Cardiovascular Surgery researchers evaluated the impact of pulmonary hypertension (PH) and right ventricular (RV) function on outcomes of isolated tricuspid valve (TV) surgery. The retrospective study was published in JTCVS Open.
There are few previous studies investigating the outcomes of isolated TV surgery. This study included a large cohort of patients and focused on evaluating the short- and long-term outcomes stratified by the presence of two major risk factors for poor survival after TV surgery — PH and RV dysfunction.
Needing guidelines
The bleak prognosis associated with severe tricuspid regurgitation (TR) has drawn the attention of the international cardiology community. There is an urgent need for comprehensive TR treatment guidelines.
The lack of high-level evidence-based clinical guidelines on when a surgical referral is necessary creates a major challenge. Current guidelines fall short in determining:
- Patient selection criteria.
- Optimal treatment strategy.
- Technique selection tailored to the stage and pathology of TR.
- Timing for surgical versus transcatheter valve interventions.
"Tricuspid regurgitation is common in the population, and it's often ignored. For patients with tricuspid regurgitation, the more severe the degree, the greater the association with worse long-term survival," says Juan A. Crestanello, M.D., a cardiovascular surgeon and the chair of Cardiovascular Surgery at Mayo Clinic in Rochester, Minnesota. Dr. Crestanello is one of the study's authors. "It's not only survival but also the impact tricuspid regurgitation has on quality of life. Patients may experience shortness of breath, lower extremity edema, ascites, and kidney and liver dysfunction. Often patients with tricuspid regurgitation have many comorbidities."
Mayo Clinic Cardiovascular Surgery multidisciplinary specialists support rigorous patient categorization, particularly with respect to the grade of PH and RV dysfunction, to improve risk stratification. Due to the complexities, treatment decisions for patients with severe TR should be made through a heart team approach.
Most tricuspid valve operations for TR occur during other cardiac procedures. Performing a stand-alone TV repair or replacement for significant TR comprises less than 5% of all cardiac valve operations. Often, patients with advanced disease are referred to cardiac surgeons late.
Weighing TV surgery parameters
The researchers looked at the impact of the presence of PH with and without RV dysfunction and RV dysfunction without PH in a large cohort of patients undergoing isolated TV surgery at Mayo Clinic.
"Pulmonary hypertension and right ventricular dysfunction are two parameters that are used to determine the timing of tricuspid valve surgery and have significant impact in the outcomes of patients undergoing tricuspid valve surgery. The interaction between them has not been fully elucidated and we sought to investigate," says Dr. Crestanello.
This study provides echocardiographic and clinical parameters. Echocardiographic data was used to assess the outcomes of isolated TV surgery in high-risk patients who are often not offered intervention.
"We evaluated almost 300 patients who had isolated tricuspid valve surgery. The patients were stratified based on the presence or absence of RV dysfunction and of pulmonary hypertension in four groups. We found that the presence of either RV dysfunction or pulmonary hypertension does not increase operative mortality. However, the presence of either one before surgery was associated with decreased long-term survival," says Dr. Crestanello. "Surprisingly, when both pulmonary hypertension and RV dysfunction coexist, there was no increased long-term mortality."
Study highlights
- The research included 298 patients.
- The median age was 71 and 59.4% were female.
- A total of 188 patients had previous cardiac surgery.
- Most patients (73.2%) underwent TV replacement.
- The most common valve repair technique was band annuloplasty (47.5%).
Early intervention success
The research shows why early surgical referral for TR is key. "This study highlighted the importance of early intervention on the tricuspid valve before the development of right ventricular dysfunction or pulmonary hypertension," says Dr. Crestanello. "Tricuspid valve regurgitation significantly impacts the patient's long-term survival. Operating before the development of either PH or RV dysfunction leads to improved long-term outcomes."
What's next
In addition to the evidence that supports the need to implement guidelines for timely surgical referrals, the research may inspire future investigation. "This study provides the background against which transcatheter therapies for tricuspid regurgitation can be compared," says Dr. Crestanello. "Similar studies can be performed on patients with tricuspid regurgitation being treated with transcatheter therapies stratified by the presence of pulmonary hypertension and RV dysfunction."
For more information
Altarabsheh SE, et al. Impact of pulmonary hypertension and right ventricular function on outcomes of isolated tricuspid valve surgery. JTCVS. 2025;24:115.
Refer a patient to Mayo Clinic.