Tricuspid Valve #1: Surgeon’s View

1) Intra-atrial orientation: “Map first, judge later”

From the right atrium, the tricuspid valve is best approached as a commissure-defined, three-leaflet ring. Before interpreting leaflet pathology or regurgitant jets, establish a fixed right-atrial roadmap:

• SVC and IVC orifices: define the superior–inferior axis and help maintain consistent spatial orientation.
• Coronary sinus (CS) ostium: key inferoposterior landmark; also a “safety reference” when working near the septal annulus. [1,2]
• Tendon of Todaro: points toward the conduction region and forms a boundary of the Triangle of Koch. [1]

Once this RA map is set, commissural defects, clefts, and jet direction can be localized more reliably and translated into a repair plan. [1]

2) Surgical leaflet map: what you are actually repairing

A surgeon-facing framework is three leaflets + commissures:

1. Anterior leaflet
• Commonly the largest and most mobile leaflet segment. [2]
2. Septal leaflet
• Functionally critical because the septal annulus is conduction-adjacent. [1,2]
3. Posterior leaflet
• Often multi-scalloped, which can obscure commissural boundaries unless the annulus is systematically mapped. [2]

Key principle: commissures define the operative “repair geography.” Repairs should respect native commissural boundaries rather than creating artificial leaflet edges after annular distortion. [2]

3) Conduction safety: Triangle of Koch discipline

Tricuspid repair uniquely demands a conduction-first mindset, because the septal annulus lies near the Triangle of Koch (AV node region). [1,2]

Operative implications

• In the septal annulus zone, place sutures superficially and precisely, avoiding deep bites that risk AV node/His injury. [1]
• Use the CS ostium and tendon of Todaro as constant reference points when placing septal stitches; anchoring strategy near the CS can help maintain a safe trajectory. [1]
• Treat the septal annulus differently from the free-wall annulus: fewer deep “bite-and-pull” maneuvers, tighter control of depth, spacing, and needle angle. [1,2]

4) Mechanism-based TR assessment: classify the failure mode

High-quality repair begins with a mechanism diagnosis, not the TR grade alone. The dominant drivers are often:

A. Annular dilation (functional TR)

• Leaflets may be structurally normal, but coaptation fails because the annulus enlarges (often in the setting of RA/RV remodeling). [2]

B. Leaflet pathology (primary TR)

• Cleft/commissural lesions, prolapse, restriction, dysplasia, or tissue deficiency. [2,7]

C. Subvalvular/RV geometry (tethering-dominant TR)

• Papillary displacement and leaflet tethering due to RV remodeling can dominate and may limit the effectiveness of annuloplasty alone. [2,4]

This framework matters because annuloplasty is necessary but not always sufficient when tethering or leaflet pathology is the major driver. [2,4]

5) Evidence-informed repair strategy: what tends to last

Large comparative surgical series consistently show better durability with ring-based annuloplasty than with suture-only or patch/band alternatives:

• In a large cohort undergoing concomitant TV procedures for secondary TR, rigid ring annuloplasty showed the most sustained reduction in significant recurrent TR compared with commissural or leaflet-only approaches. [4]
• Comparative durability data similarly demonstrate worse late performance of suture-based techniques (e.g., De Vega) and certain patch-based approaches versus ring annuloplasty. [5]
• In patients with functional TR undergoing left-sided valve surgery, evidence supports a more proactive annuloplasty approach rather than observation alone in appropriate phenotypes. [6]
• Contemporary surgical teaching reviews emphasize that technique selection should be mechanism-driven, with deliberate attention to annular dynamics, leaflet configuration, and the conduction risk zone. [1,7]
• Review-level synthesis in functional TR reinforces that rigid/semi-rigid ring strategies tend to be more durable than suture- or flexible band–based repairs. [9]

6) Pediatric/single-ventricle reality check: durability constraints are different

In single-ventricle populations with systemic RV physiology, tricuspid repair failure remains common and strongly prognostic:

• Multicenter experience demonstrates frequent repair failure and recurrent TR, with outcomes closely linked to whether the repair achieves and maintains meaningful reduction in regurgitation. [8]
• In this setting, combined annuloplasty + leaflet repair has not consistently proven superior to annuloplasty alone across cohorts, underscoring the heterogeneity of mechanisms and the limits of “one recipe.” [8]

7) Practical “current” adjuncts that improve quality

Even when surgical concepts are classic, outcomes improve when execution is systematically modernized:

• 3D echocardiography / multimodality imaging to define commissures, tethering geometry, and coaptation gaps—useful for pre-repair planning and post-repair verification. [3]
• Mechanism-guided repair selection (annular vs leaflet vs tethering-dominant) to avoid under-treating tethering or over-relying on annuloplasty. [2,4,7]
• Intraoperative valve testing + echo correlation with a concrete target: broad coaptation, minimal residual eccentric jets, and avoidance of iatrogenic stenosis. [1,3,7]

References

[1] Saran N, Dearani JA. Tricuspid Valve Repair: How I Teach It. Ann Thorac Surg. 2018;105(3):675-679. doi:10.1016/j.athoracsur.2017.08.063.

[2] Buzzatti N, De Bonis M, Moat N. Anatomy of the Tricuspid Valve, Pathophysiology of Functional Tricuspid Regurgitation, and Implications for Percutaneous Therapies. Interv Cardiol Clin. 2018;7(1):1-11. doi:10.1016/j.iccl.2017.08.005.

[3] Wunderlich NC, Landendinger M, Arnold M, et al. State-of-the-Art Review: Anatomical and Imaging Considerations During Transcatheter Tricuspid Valve Repair Using an Annuloplasty Approach. Front Cardiovasc Med. 2021;8:619605. doi:10.3389/fcvm.2021.619605.

[4] Navia JL, Nowicki ER, Blackstone EH, et al. Surgical management of secondary tricuspid valve regurgitation: annulus, commissure, or leaflet procedure? J Thorac Cardiovasc Surg. 2010;139(6):1473-1482.e5. doi:10.1016/j.jtcvs.2010.02.046.

[5] McCarthy PM, Bhudia SK, Rajeswaran J, et al. Tricuspid valve repair: durability and risk factors for failure. J Thorac Cardiovasc Surg. 2004;127(3):674-685. doi:10.1016/j.jtcvs.2003.11.019.

[6] Pagnesi M, Montalto C, Mangieri A, et al. Tricuspid annuloplasty versus a conservative approach in patients with functional tricuspid regurgitation undergoing left-sided heart valve surgery: A study-level meta-analysis. Int J Cardiol. 2017;240:138-144. doi:10.1016/j.ijcard.2017.05.014.

[7] Saran N, Dearani JA. Strategies for tricuspid valve repair. Indian J Thorac Cardiovasc Surg. 2020;36(Suppl 1):123-130. doi:10.1007/s12055-019-00826-x.

[8] Muntaner CD, King G, Zannino D, et al. Poor Late Outcomes After Tricuspid Valve Repair in a Single-Ventricle Population. Ann Thorac Surg. 2021;111(3):986-993. doi:10.1016/j.athoracsur.2020.05.070.

[9] Rogers JH, Bolling SF. Valve Repair for Functional Tricuspid Valve Regurgitation. Circulation. 2010;121(1):102-114. doi:10.1161/CIRCULATIONAHA.108.842773.