Tricuspid repair: ring annuloplasty remains the gold standard

Tricuspid regurgitation: breaking the therapeutic inertia

Long-considered the "forgotten valve," the tricuspid valve is undergoing a major clinical paradigm shift. This scientific review addresses the historical therapeutic inertia that assumed, often incorrectly, that tricuspid regurgitation (TR) would resolve on its own following the treatment of left-sided lesions. The authors demonstrate that untreated functional TR is an independent driver of morbidity, leading inexorably to irreversible right ventricular (RV) dysfunction and systemic venous congestion.

The objective of this synthesis is to evaluate the effectiveness of contemporary surgical repair techniques — primarily annuloplasty — in the face of the anatomical constraints of the RV-tricuspid complex. Based on the analysis of large-scale clinical cohorts, including a series of 1,346 patients, the study specifies threshold surgical indications: annular dilatation exceeding 40 mm (or 21 mm/m² indexed) becomes a criterion for intervention, even for moderate TR during combined surgery. Finally, the review examines post-operative conduction risks, reporting a significant permanent pacemaker implantation rate, ranging between 10.3% and 14.1% depending on the series analyzed. The central hypothesis rests on the necessity of early intervention to halt deleterious ventricular remodeling.

Methodological approach and data sources

This publication constitutes a qualitative review of the scientific literature. It aims to synthesize contemporary surgical techniques for tricuspid valve repair, putting them into perspective with the emergence of percutaneous therapies. The authors have structured their analysis by integrating data from clinical trials, national registries, and expert consensus from learned societies (AHA/ACC and ESC).

To document clinical outcomes and associated risks, the review is based on the analysis of several significant cohorts reported in the literature:

• A retrospective study including 1,346 patients operated on between 2011 and 2022.
• A longitudinal series of 1,058 patients treated by tricuspid repair over a 22-year period (1997-2019).
• The evaluation of the incidence of electrical complications, particularly the permanent pacemaker implantation rate.

Analysis criteria include echocardiographic parameters (annulus diameter > 40 mm or > 21 mm/m²), the severity of tricuspid regurgitation (TR), and the status of right ventricular function. The authors detail the principles of ring annuloplasty (rigid or semi-rigid) and leaflet reconstruction techniques according to primary or secondary etiologies.

Intervention criteria and biometric thresholds

Compiled data confirm that the success of tricuspid surgery relies on precise timing, before the onset of irreversible right ventricular (RV) dysfunction. The operative indication becomes imperative as soon as the tricuspid annulus diameter reaches critical thresholds, even in the presence of moderate tricuspid regurgitation (TR).

• Annular dilatation threshold: Diameter > 40 mm (or > 21 mm/m² in indexed diameter).
• Clinical benefit: Concomitant repair during mitral surgery significantly reduces the reoperation rate for TR, the progression of regurgitation severity (gain of two grades), and mortality at 2 years.

The risk of permanent cardiac stimulation

One of the major findings of this review concerns the significant incidence of permanent pacemaker (PM) implantation post-surgery. This risk, linked to the proximity of the conduction tissue in the Koch triangle, varies according to the cohorts studied:

Source / Population	Sample size (n)	Taux d'implantation PM (%)
Clinical trial (concomitant RT at 2 years)	Veuillez fournir le texte HTML source à traduire.	14.1 %
Retrospective study (Michigan, 2011-2022)	1 346	11.0 %
Surgical series (1997-2019)	1,058	10.3%
Medicare beneficiaries (65-99 years old)	Veuillez fournir le texte HTML source à traduire.	12.7 %

Preoperative evaluation and multimodal imaging

The choice of surgical technique (annuloplasty vs. replacement) is dictated by a detailed analysis of the RV geometry and the valvular apparatus. Imaging plays a pivotal role here for the practitioner:

• Echocardiography (TTE/TOE 3D): Essential for quantifying the regurgitant orifice and guiding the intraoperative procedure.
• Cardiac CT scan: Allows for the delineation of annular geometry, calcifications, and the proximity of coronary arteries.
• Cardiac MRI: Recognized as the gold standard for the precise evaluation of right ventricular volumes, particularly useful when the ultrasound window is limited.

Repair techniques: annuloplasty as the standard

Ring annuloplasty (rigid or semi-rigid) stands as the gold standard compared to suturing techniques (Kay or De Vega). The latter, although faster and requiring less prosthetic material (an advantage in cases of active infection), show higher TR recurrence rates. Contemporary rings, which are more flexible, aim to respect the non-planar three-dimensional shape of the tricuspid annulus while limiting stress on the atrioventricular node.

Practice analysis: towards a standardization of the procedure

The data from this review confirm the paradigm shift: the tricuspid valve is no longer the forgotten one. The analysis highlights that ring annuloplasty (rigid or semi-rigid) remains the gold standard compared to Kay or De Vega suture techniques, the latter presenting a higher risk of tricuspid regurgitation (TR) recurrence despite their utility in cases of active infection. Clinical relevance relies on timing: intervening before irreversible right ventricular failure. Multimodal imaging — 3D TOE for leaflet visualization and MRI for RV volumes — now allows for precise objectification of annular dilation (threshold of 40 mm or 21 mm/m²) to guide the surgical procedure.

The major point of vigilance identified by the authors concerns the conduction system. The various compiled studies report significant rates of permanent pacemaker implantation: 14.1% at 2 years for concomitant surgeries, 11% in the Michigan cohort, and 10.3% in another large series of 1058 patients. This morbidity requires rigorous technical precision during the placement of rings or flexible bands, particularly to avoid the conduction tissues located in the triangle of Koch.

In conclusion, while the repair is safe and technically mature, the challenge remains the balance between the efficiency of annular remodeling and the preservation of sinus rhythm. The emergence of minimally invasive and robotic techniques, cited in the review, allows for the discussion of intervention earlier in the care pathway, thus limiting deleterious ventricular remodeling.

Review summary

This review highlights that ring annuloplasty remains the surgical standard for tricuspid regurgitation (TR), although compiled data (trials and registries) reveal a significant risk of permanent cardiac pacing, ranging between 10.3% and 14.1%. The analysis reaffirms the annular dilation threshold of 40 mm as a major decision-making criterion to prevent irreversible right ventricular dysfunction.

In concrete terms, for the practitioner:

• Optimizing timing: Do not wait for advanced right-sided failure; an annular dilatation > 40 mm (or > 21 mm/m²) justifies intervention, even if the insufficiency is clinically moderate, particularly during concomitant mitral surgery.
• Technical arbitration: Prioritize the rigid or semi-rigid prosthetic ring for its superior durability, while maintaining suturing techniques (Kay/De Vega) for active infection cases to limit foreign material.
• Patient information: Explicitly integrate the risk of postoperative pacemaker (estimated between 11% and 14%) into the informed consent, as this risk is a documented consequence of corrective ring surgery.
• Multimodal exploration: In addition to TTE, use 3D TEE for visualization of the leaflets and do not hesitate to request cardiac MRI for an accurate assessment of RV volumes in case of limited ultrasound windows.

For decades, the tricuspid valve has been relegated to the background, often eclipsed by mitral or aortic pathologies. This therapeutic inertia was based on a common misconception: that tricuspid regurgitation (TR) is either benign or resolvable after correction of left-sided lesions. Contemporary data challenge this paradigm. Untreated TR proves to be a powerful driver of morbidity, leading inexorably to right ventricular dysfunction and systemic venous congestion.

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