May 17, 2025
A healthy tricuspid valve allows blood to flow to the right ventricle where it's pumped into the lungs for oxygen. But with a leaky tricuspid valve, blood can stream backward, and this forces the heart to pump harder. The heart eventually becomes enlarged and doesn't function well.
Tricuspid valve repair and tricuspid valve replacement can help reduce the symptoms of heart valve disease by improving blood flow. These surgeries to treat damaged and diseased tricuspid valves may be done as open-heart or minimally invasive heart operations. Sometimes, catheter-based procedures — transcatheter tricuspid valve replacement (TTVR) — are performed.
The forgotten valve
The challenging tricuspid is sometimes considered the forgotten valve. "The tricuspid valve has been rarely operated on as an isolated valve issue. This is because tricuspid regurgitation is generally well tolerated and the risk of isolated tricuspid valve surgery has historically been thought to be quite high," says Kristen A. Sell-Dottin, M.D., a cardiothoracic surgeon and surgical director for Structural Heart Disease at Mayo Clinic in Arizona.
There is some increased surgical risk with tricuspid valve repair or replacement due to the concerns for right ventricular dysfunction or failure. Challenging to treat, right ventricular dysfunction can lead to renal failure, liver dysfunction or heart rhythm concerns.
Many patients with tricuspid valve disease exhibit multiple comorbidities, which can make surgery more complex. As leaders in complex tricuspid surgeries, Mayo Clinic cardiac surgeons have extensive experience treating:
- Tricuspid valve disease including functional tricuspid regurgitation.
- Carcinoid heart disease.
- Tricuspid regurgitation linked to congenital heart disease.
- Pacemaker-induced tricuspid regurgitation.
- Tricuspid regurgitation associated with atrial fibrillation.
Despite the possible concerns with operating, the surgical risk of tricuspid valve replacement is not as high as initially reported due to better:
- Risk stratification where the operation is offered to patients who are likely to do well.
- Medical therapy to help treat pulmonary hypertension and right ventricular dysfunction.
- Mechanical circulatory support options available to help patients through the perioperative period.
Transcatheter possibilities
Transcatheter tricuspid valve replacement is advancing valve therapy, but it's important to know the risks. "There are procedural risks that include possible malposition of the transcatheter valve or incomplete capture of the native valve, leading to a leak around the valve prosthesis. There are also some unknown risks because this is still a new technology and we don't yet understand exactly how this valve is going to behave," says Dr. Sell-Dottin.
The same risks would be involved as with a surgical tricuspid valve replacement. Additionally, if the transcatheter valve fails, it may need to be removed. "We don't yet know how risky the explant of one of these transcatheter valves will be. But given the size and the mechanism in which it anchors in place, this would be a tricky surgery that would come with significant risks," says Dr. Sell-Dottin.
With valve therapy, there are well-established transcatheter aortic valve prostheses. There are several transcatheter mitral valve interventions that are currently available or in trial, as well as transcatheter options to treat pulmonic valve disease.
"The tricuspid valve is the 'last frontier' in that there is a minimal fibrous skeleton of the heart present around the tricuspid annulus. This makes it difficult to anchor a transcatheter valve in this position," says Dr. Sell-Dottin. "Additionally, the mode of failure of the tricuspid valve often involves annular dilatation, so the valve prostheses needed to treat this are large."
Pioneering tricuspid valve repair
Mayo Clinic cardiac surgeons are pioneers in the field of tricuspid valve repair and tricuspid valve replacement surgery. The unique aspects of Mayo Clinic's approach to treatment of tricuspid valve replacement surgery involve a multidisciplinary approach to selection and management of patients. Valve specialists, echocardiographers, heart failure cardiologists and interventional cardiologists convene with cardiac surgeons to discuss complex cases. "We are careful about selecting the most appropriate procedure for each patient: tricuspid-clip, transcatheter tricuspid valve replacement, or surgical tricuspid valve repair or replacement," says Dr. Sell-Dottin.
The traditional approach has been to wait and watch with the tricuspid valve. But Mayo Clinic cardiac surgeons are intervening earlier. It's crucial not to merely monitor tricuspid disease as it progressively deteriorates. Early referral to a center with expertise is key for better outcomes and quality of life.
"As we have realized our ability to risk stratify and optimize patients preoperatively, we've also found that proceeding with surgery before the development of significant right ventricular failure or other end organ dysfunction is lower risk," says Dr. Sell-Dottin. "We prefer to intervene earlier once we identify that a patient has significant enough tricuspid valve dysfunction to warrant intervention."
Mayo Clinic is well positioned to take care of these complex patients due to the thoughtful evaluation and decision-making of a multidisciplinary team. "This leads to optimization of patients prior to surgery and goal-directed medical therapy postoperatively," says Dr. Sell-Dottin. "We make sure patients have close follow-up as they are recovering from tricuspid valve surgery with valve specialists or heart failure physicians."
For more information
Refer a patient to Mayo Clinic.