• tricuspid valve disease
• valve disease surgery
• heart failure

Moderate to severe tricuspid regurgitation (TR) is associated with increased morbidity and mortality, both in isolation and in combination with left-sided heart disease.1 2 Of the 1.6 million patients in the USA with moderate to severe TR, the vast majority have functional TR in the setting of left-sided heart disease and associated pulmonary hypertension.

Clinicians have long struggled with how to optimally manage these patients. Diuretics are a mainstay of medical therapy, and for those with concomitant heart failure with a reduced ejection fraction (HFrEF), optimal medical therapy (OMT) is recommended. In general, however, medical therapy will not reverse progressive right ventricular dysfunction with significant TR and has not been associated with beneficial long-term effects. Surgical intervention via tricuspid valve repair or replacement more definitively addresses valvular dysfunction, and according to current American College of Cardiology/American Heart Association guidelines is recommended in patients with severe TR undergoing left-sided valve surgery (class I), mild or greater TR combined with either tricuspid annular dilation or right-sided heart failure at the time of left-sided valve surgery (class IIa), and isolated severe TR with symptoms (class IIa) or with associated right ventricular dysfunction (class IIb).3 Despite these recommendations, however, less than 8000 tricuspid valve surgeries (TVS) are performed annually in the USA, of which only 500 are for isolated TR.1 This is primarily due to perceived surgical risk in patients with multiple comorbidities. Indeed, in-hospital mortality for patients receiving TVS has been estimated at approximately 8%–10%. Given the associated surgical risks, surgical intervention may be delayed in lieu …