- •
The tricuspid valve is a complex dynamic structure whose function depends on the harmony of several different components: annulus, leaflets, chordae, papillary muscles, and right ventricle.
- •
Several nonvalvular structures, such as the coronary sinus ostium, the conduction system, the membranous septum, and the right coronary artery are in close relationship with the tricuspid annulus.
- •
Annulus dilation and leaflet tethering due to right ventricle remodeling are the 2 major pathophysiologic
Anatomy of the Tricuspid Valve, Pathophysiology of Functional Tricuspid Regurgitation, and Implications for Percutaneous Therapies
Section snippets
Key points
Anatomy
Gross anatomy of the tricuspid valve and of the right heart is depicted in Figs. 1 and 2.
Pathophysiology of functional tricuspid regurgitation
Tricuspid regurgitation (TR) is known to be associated with increased morbidity and mortality.18, 19 There are many different etiologies of TR. Functional TR (fTR) is currently the most common form of TR in Western countries.20 fTR is a continuum and a dynamic process, extremely dependent on heart loading conditions.
Implications for percutaneous therapies
The spread of percutaneous transcatheter technologies has finally reached the tricuspid valve.3 Several important implications for these devices can be derived from tricuspid anatomy, pathophysiology, and surgical experience:
- •
Tricuspid anatomy is huge. It is the biggest of the heart valves, bigger than the mitral, and it gets even bigger in the setting of severe TR. The issue is clear if the mean CT-measured area of a regurgitant tricuspid valve is compared with the cross-sectional area of an
Summary
The tricuspid valve presents complex anatomy and function, with many nearby structures that require careful consideration. The RV plays a crucial role in fTR, although its assessment remains to be fully clarified. Understanding the anatomy and the function of the tricuspid AV valve within the right heart is fundamental for the development of transcatheter tricuspid valve technologies. Careful preprocedural planning with 3-D echo and CT is crucial to tailor the treatment to specific patients and
Acknowledgments
The authors would like to thank Dr Teodora Nisi for the hand drawings.
References (47)
- et al.
5-year outcomes of transcatheter aortic valve replacement or surgical aortic valve replacement for high surgical risk patients with aortic stenosis (PARTNER 1): a randomised controlled trial
Lancet
(2015) - et al.
Randomized comparison of percutaneous repair and surgery for mitral regurgitation: 5-year results of EVEREST II
J Am Coll Cardiol
(2015) - et al.
Transcatheter therapies for treating tricuspid regurgitation
J Am Coll Cardiol
(2016) - et al.
Adult human valve dimensions and their surgical significance
Am J Cardiol
(1984) - et al.
Guidelines for the echocardiographic assessment of the right heart in adults: a report from the American Society of Echocardiography endorsed by the European Association of Echocardiography, a registered branch of the European Society of Cardiology, and the Canadian Society of Echocardiography
J Am Soc Echocardiogr
(2010) Morphology of the human atrioventricular node, with remarks pertinent to its electrophysiology
Am Heart J
(1961)- et al.
Impact of tricuspid regurgitation on long-term survival
J Am Coll Cardiol
(2004) - et al.
Secondary mitral and tricuspid regurgitation accompanying left ventricular systolic dysfunction: is it important, and how is it treated?
Am Heart J
(2002) - et al.
Echocardiography-based spectrum of severe tricuspid regurgitation: the frequency of apparently idiopathic tricuspid regurgitation
J Am Soc Echocardiogr
(2007) - et al.
Determinants of the severity of functional tricuspid regurgitation
Am J Cardiol
(2006)
Echocardiographic follow-up of tricuspid annuloplasty with a new three-dimensional ring in patients with functional tricuspid regurgitation
J Am Soc Echocardiogr
Functional tricuspid regurgitation in patients with pulmonary hypertension: is pulmonary artery pressure the only determinant of regurgitation severity?
Chest
Trends and outcomes of tricuspid valve surgery in North America: an analysis of more than 50,000 patients from the Society of Thoracic Surgeons database
Ann Thorac Surg
Tricuspid regurgitation is uncommon after mitral valve repair for degenerative diseases
J Thorac Cardiovasc Surg
Tricuspid annular size and regurgitation progression after surgical repair for degenerative mitral regurgitation
Am J Cardiol
Secondary tricuspid regurgitation or dilatation: which should be the criteria for surgical repair?
Ann Thorac Surg
Reoperations after tricuspid valve repair
J Thorac Cardiovasc Surg
Direct injury to right coronary artery in patients undergoing tricuspid annuloplasty
Ann Thorac Surg
First-in-human transcatheter tricuspid valve repair in a patient with severely regurgitant tricuspid valve
J Am Coll Cardiol
Afterload mismatch after MitraClip insertion for functional mitral regurgitation
Am J Cardiol
Cardiac computed tomography and magnetic resonance imaging in the evaluation of mitral and tricuspid valve disease: implications for transcatheter interventions
Circ Cardiovasc Imaging
Imaging evaluation of tricuspid valve: analysis of morphology and function with CT and MRI
AJR Am J Roentgenol
3D geometry of a normal tricuspid annulus during systole: a comparison study with the mitral annulus using real-time 3D echocardiography
Eur J Echocardiogr
Cited by (20)
Animal model considerations to evaluate prosthetic tricuspid valve implants
2021, Annals of AnatomyCitation Excerpt :Atrial and ventricular cavities are not dilated as in diseased patients, and so tissue interaction with devices is different. Tricuspid annulus dilatation is one of the consequences of functional tricuspid regurgitation (Buzzatti et al., 2018). Rapid cardiac pacing or direct alteration of the native anatomy can be used to develop a model of heart dilatation (Hoppe et al., 2007; Malinowski et al., 2017) but it remains difficult to stabilize and keep sick animals alive in good and ethically acceptable condition.
Burden of Tricuspid Regurgitation in Patients Undergoing Coronary Artery Bypass Grafting
2021, Annals of Thoracic SurgeryCitation Excerpt :Tricuspid regurgitation presents in two main forms: organic (primary), and functional (secondary).2 Whereas organic involves primary pathology of the valve leaflets, functional—the most common form of TR—is characterized by dilated right ventricle and tricuspid annulus with right ventricular failure or pulmonary hypertension.2,22,23 Common causes include left-sided valve pathology, atrial fibrillation, and ischemic changes to right ventricle.1,2
Transcatheter tricuspid valve repair: Bringing the forgotten valve into the spotlight
2020, Journal of Thoracic and Cardiovascular SurgeryScaffolds for engineering heart valve
2019, Handbook of Tissue Engineering Scaffolds: Volume OneTranscatheter Tricuspid Valve Interventions: Landscape, Challenges, and Future Directions
2018, Journal of the American College of CardiologyCitation Excerpt :Finally, as the right ventricle continues to remodel, further leaflet tethering worsens, resulting in a lack of coaptation and massive or torrential TR. When severe tethering occurs, any repair attempt could be considered futile, and TTVR should be preferred over TTVr (81). Orthotopic TTVR should be first considered for patients with preserved or mild to moderate right ventricular dysfunction.
Disclosure Statement: The authors have nothing to disclose.