Functional tricuspid regurgitation: An underestimated issue

doi:10.1016/j.ijcard.2013.04.043

International Journal of Cardiology

Volume 168, Issue 2, 30 September 2013, Pages 707-715

https://doi.org/10.1016/j.ijcard.2013.04.043 Get rights and content

Abstract

This review article focuses on functional tricuspid regurgitation (FTR) that has long been a neglected and underestimated entity. FTR is defined as leakage of the tricuspid valve during systole in the presence of structurally normal leaflets and chordae. FTR may be secondary to several heart diseases, more commonly mitral valve disease, pulmonary hypertension, atrial fibrillation, cardiomyopathies, right ventricular dysplasia, and idiopathic annular dilatation. The reported prevalence of moderate or greater FTR is roughly 16%, but it rises up to 89% when considering FTR of any grade. According to the recommendations of the European Association of Echocardiography, two-dimensional transthoracic echocardiography (TTE) is the first-line imaging modality for the assessment of valvular regurgitation, whereas three-dimensional TTE may provide additional information in patients with complex valve lesions. Transesophageal echocardiography may be used when TTE results are inconclusive. The natural history of FTR is unfavorable, even in less than severe tricuspid regurgitation. Data from the literature suggest that moderate or greater FTR is a risk factor for worse survival. In addition, FTR of any grade may worsen over time, which makes it reasonable to consider the correction of FTR at an early stage, preferably at the time of mitral valve surgery. Tricuspid valve annuloplasty is the gold standard surgical treatment for FTR and is associated with a recurrence rate, defined as postoperative moderate or severe FTR, ranging from 2.5 to 5.5% at 1-year follow-up.

Introduction

Functional tricuspid regurgitation (FTR) has long been a neglected and underestimated entity. As it usually occurs secondary to mitral valve (MV) disease, cardiologists and cardiac surgeons have long argued that if regurgitation was “functional”, then it should improve when the MV is treated. However, more recently, FTR has gained increasing recognition in both clinical and surgical settings. The purpose of this review was to discuss the insights of epidemiology, pathogenesis, natural history and surgery of FTR. A special focus was placed on the need for early identification and careful quantification of FTR in order to optimize surgical indications, because the clinical course of the disease may vary according to the several etiologies of FTR.

The literature search was performed using primarily the Medline database, but other databases were also considered (CTSNet, CASPUR, Ovid, ScienceDirect).

Section snippets

Definition

FTR is a complex valvular lesion in which the tricuspid valve (TV) leaks during systole in the presence of structurally normal leaflets and chordae. FTR is considered a “ventricular” disease.

Etiology and epidemiology

FTR can be secondary to several heart diseases, but it is usually associated with MV disease, pulmonary hypertension, atrial fibrillation, or cardiomyopathy [1].

Calafiore et al. [2] reported a prevalence of moderate to severe FTR of up to 63% of patients with mitral stenosis. The prevalence of moderate or severe FTR ranges largely from 8% to 45% in patients undergoing MV surgery for mitral regurgitation (MR). Dreyfus et al. [3] found that 8% of patients had moderate to severe FTR at the time of

Anatomical remarks

The TV apparatus is very complex. The recent introduction of real-time three-dimensional echocardiography (RT3DE) has allowed to obtain new important geometric insights into the pathophysiological mechanisms underlying FTR [10], [11]. The TV consists of three leaflets and a non-planar, elliptical saddle-shaped annulus. The anterior leaflet is the largest, followed by the posterior leaflet, which arises from the posterior margin of the annulus from the septum to the infero-lateral wall, whereas

Pathophysiological mechanisms underlying functional tricuspid regurgitation

In FTR, the TV leaflets fail to coapt because of the geometrical distortion of the normal spatial relationships.

Dilatation of the tricuspid annulus occurs primarily in the anterior and posterior directions, as the small septal wall leaflet is fairly fixed [13] (Fig. 3). The annulus becomes more circular with a decreased medial-lateral/antero-posterior ratio (1.11 ± 0.09 versus 1.32 ± 0.09, p < 0.001) [13]. Both maximum (7.5 ± 2.1 versus 5.6 ± 1.0 cm²/m², p < 0.003) and minimum (5.7 ± 1.3 versus 3.9 ± 0.8 cm²/m²,

Echocardiographic assessment

According to the recommendations of the European Association of Echocardiography (EAE) [18], two-dimensional transthoracic echocardiography (2DTTE) is the first-line imaging modality for the assessment of valvular regurgitation. 3DTTE may provide additional information in patients with complex valve lesions and TEE may be used when TTE results are inconclusive.

Clinical presentation, natural history and surgical indications

FTR can arise from a variety of causes, including RV enlargement due to left-sided heart valve disease, LV or RV dysfunction, pulmonic stenosis or regurgitation, pulmonary hypertension, and dilated cardiomyopathy. Patients with FTR present with signs and symptoms of either right-sided heart failure or other underlying conditions. In TR, chronic RV volume overload results in right-sided congestive heart failure manifested by liver congestion, peripheral edema and ascites. In FTR secondary to LV

Surgical procedures and results

Prophylactic surgical strategies for TV repair are directed mainly to the annulus. Reshaping of the tricuspid annulus can be obtained using suture annuloplasty or a support device that relieves stress on the native annulus, such as a pericardial strip, an incomplete ring (planar or shaped, rigid, or semi-rigid) (Fig. 7), or a flexible band [37], [38].

In patients undergoing curative intent surgery, RV dilatation and severe tethering are frequently observed. In these circumstances, TV

References (48)

J. Hung
The pathogenesis of functional tricuspid regurgitation
Semin Thorac Cardiovasc Surg
(2010)
A.M. Calafiore et al.
Echocardiographic-based treatment of functional tricuspid regurgitation
J Thorac Cardiovasc Surg
(2011)
G.D. Dreyfus et al.
Secondary tricuspid regurgitation or dilatation: which should be the criteria for surgical repair?
Ann Thorac Surg
(2005)
P.M. McCarthy
Adjunctive procedures in degenerative mitral valve repair: tricuspid valve and atrial fibrillation surgery
Semin Thorac Cardiovasc Surg
(2007)
A. Shiran et al.
Tricuspid regurgitation in mitral valve disease: incidence, prognostic implications, mechanism, and management
J Am Coll Cardiol
(2009)
J. Hung et al.
Usefulness of echocardiographic determined tricuspid regurgitation in predicting event-free survival in severe heart failure secondary to idiopathic-dilated cardiomyopathy or to ischemic cardiomyopathy
Am J Cardiol
(1998)
A.M. Calafiore et al.
Mitral valve surgery for functional mitral regurgitation: should moderate-or-more tricuspid regurgitation be treated? A propensity score analysis
Ann Thorac Surg
(2009)
J. Nath et al.
Impact of tricuspid regurgitation on long-term survival
J Am Coll Cardiol
(2004)
H.M. Sadeghi et al.
Does lowering pulmonary arterial pressure eliminate severe functional tricuspid regurgitation? Insights from pulmonary thromboendarterectomy
J Am Coll Cardiol
(2004)
A. Sagie et al.
Determinants of functional tricuspid regurgitation in incomplete tricuspid valve closure: Doppler color flow study of 109 patients
J Am Coll Cardiol
(1994)

S. Fukuda et al.

Echocardiographic insights into atrial and ventricular mechanisms of functional tricuspid regurgitation

Am Heart J

(2006)

H.K. Kim et al.

Determinants of the severity of functional tricuspid regurgitation

Am J Cardiol

(2006)

F. Roshanali et al.

Echocardiographic approach to the decision-making process for tricuspid valve repair

J Thorac Cardiovasc Surg

(2010)

J.M. Song et al.

The vena contracta in functional tricuspid regurgitation: a real-time three-dimensional color Doppler echocardiography study

J Am Soc Echocardiogr

(2011)

R.M. Lang et al.

Valvular heart disease. The value of 3-dimensional echocardiography

J Am Coll Cardiol

(2011)

K. Matsuyama et al.

Predictors of residual tricuspid regurgitation after mitral valve surgery

Ann Thorac Surg

(2003)

D. Mutlak et al.

Echocardiography-based spectrum of severe tricuspid regurgitation: the frequency of apparently idiopathic tricuspid regurgitation

J Am Soc Echocardiogr

(2007)

J.J. Kwak et al.

Development of tricuspid regurgitation late after left-sided valve surgery: a single-center experience with long-term echocardiographic examinations

Am Heart J

(2008)

P.M. McCarthy et al.

Tricuspid valve repair: durability and risk factors for failure

J Thorac Cardiovasc Surg

(2004)

H.K. Chopra et al.

Can two-dimensional echocardiography and Doppler flow mapping identify the need for tricuspid repair?

J Am Coll Cardiol

(1989)

R.K. Ghanta et al.

Suture bicuspidization of the tricuspid valve versus ring annuloplasty for repair of functional tricuspid regurgitation: midterm results of 237 consecutive patients

J Thorac Cardiovasc Surg

(2007)

F. Filsoufi et al.

A three-dimensional ring annuloplasty for the treatment of tricuspid regurgitation

Ann Thorac Surg

(2006)

S. Fukuda et al.

Echocardiographic follow-up of tricuspid annuloplasty with a new three-dimensional ring in patients with functional tricuspid regurgitation

J Am Soc Echocardiogr

(2007)

A. Sarraj et al.

Adjustable segmental tricuspid annuloplasty: technical advantages and midterm results

Ann Thorac Surg

(2009)

Cited by (49)

Tricuspid Regurgitation and Kidney Transplant Recipient Outcomes
2024, Kidney Medicine
Kidney function can be adversely affected by significant tricuspid regurgitation (TR) owing to effects on cardiac output and systemic venous congestion. However, the impact of significant TR on short- and long-term kidney function following a kidney transplant remains uncertain.
Retrospective observational cohort.
Kidney transplant recipients from a single center between 2016 and 2019.
Significant TR, defined by at least moderate regurgitation, on echocardiogram before kidney transplantation.
Primary end points included the estimated glomerular filtration rate (eGFR) at the following 3 time points: 2 weeks, 3 months, and 1 year after transplantation. Secondary end points included major adverse cardiac events including nonfatal myocardial infarction, all-cause mortality, and hospitalization owing to cardiovascular disease.
Propensity score matching was performed in 1:3 ratio between patients treated with significant TR and controls, within a caliper 0.05 standard deviation of the propensity score, to analyze for the primary end point.
Among 557 kidney transplant recipients, 26 (5%) exhibited significant TR pretransplantation. According to propensity score matching analysis, with 1:3 ratio between 24 patients with significant TR and 72 controls, the presence of significant TR was associated with a lower eGFR posttransplantation. Specifically, the mean eGFR was 41.2 mL/min/1.73 m² compared to 53.3 mL/min/1.73 m² at 2 weeks (P < 0.01), 50.0 mL/min/1.73 m² versus 60.3 mL/min/1.73 m² at 3 months (P < 0.01), and 49.4 mL/min/1.73 m² versus 61.2 mL/min/1.73 m² at 1 year (P < 0.01). Delayed graft function was observed in 41.7% of the patients with significant TR compared to 12.5% of those without significant TR (P < 0.01). No patients with significant TR required dialysis after 1 year. 1-year major adverse cardiac events were nonsignificantly higher among patients with significant TR (20.8% vs 8.1%; P = 0.16).
Retrospective design and relatively small TR population.
The presence of significant TR among kidney transplant recipients was associated with a lower eGFR at 2 weeks, 3 months, and 1 year following transplant, although all remained dialysis independent at 1 year.
Significant tricuspid regurgitation (TR) is associated with increased mortality rates and kidney failure, but its impact on kidney transplant recipients is poorly investigated. We examined how significant TR diagnosed pretransplantation affects kidney function within the first posttransplant year in a retrospective cohort study. Among 24 patients with significant TR, there was a consistent pattern of lower kidney function at 2 weeks, 3 months, and 1 year following transplantation, compared to 72 matched controls based on a propensity score. Results were statistically significant at all time points within the first year after transplant. These findings suggest that selected individuals with significant TR are able to undergo successful kidney transplantation, although with worse kidney function following transplantation.
Isolated tricuspid valve surgery. Perioperative results and medium-term survival
2021, Cirugia Cardiovascular
La cirugía valvular tricúspide aislada (QxVT) es una intervención infrecuente, considerándose un procedimiento con elevada mortalidad y evolución a medio plazo desconocida. El objetivo del presente estudio es analizar la supervivencia a medio plazo de la población intervenida de QxVT aislada, determinar los factores que influyen en la supervivencia hospitalaria y a medio plazo y la capacidad predictiva de escalas de riesgo quirúrgico habituales.
Estudio observacional, unicéntrico y retrospectivo de pacientes intervenidos de QxVT aislada desde el año 2012 hasta enero del 2020. Mediante regresión logística se analizaron factores relacionados con la mortalidad hospitalaria, y la supervivencia tardía con el método de Kaplan-Meier.
Fueron intervenidos 51 pacientes (18 anuloplastias y 33 recambios por prótesis).
El 62,75% fueron mujeres, con edad media de 66,07 años (DE 10,57). El 54% se encontraban en clase funcional III-IV de la NYHA.
La mortalidad hospitalaria observada fue del 7,8%. Los factores más influyentes en la mortalidad perioperatoria fueron la clase funcional III/IV de la NYHA (mortalidad del 0% vs. 14,3%; p Fisher = 0,13) y la anemia (OR: 11,1; IC 95%: 1,04-118,6; p = 0,046).
Se realizó seguimiento completo del 94,1%, con mediana de seguimiento de 26 meses. La supervivencia global fue del 90,1%, 84,3%, 80,2%, 75,2% a 1, 2, 3 y 4 años. Al último seguimiento, el 75% de los supervivientes se encontraban en clase funcional I-II de la NYHA.
La clase funcional preoperatoria y la anemia son factores determinantes en la supervivencia en el postoperatorio inmediato. La supervivencia a medio plazo y la mejoría de clase funcional tras QxVT aislada son satisfactorias.
Isolated tricuspid valve surgery (TVS) is an infrequent procedure, and it is considered that it entails a high surgical mortality. The objective is to analyze the medium-term survival, and to determine the variables that impact perioperative and medium-term survival. The predictive accuracy of the usual surgical risk scores was also evaluated.
Unicentric, observational retrospective study, which included all the patients operated on isolated TVS since 2012 to January 2020. Perioperative mortality was analyzed through logistic regression, and long-term survival was analyzed using the Kaplan-Meier survival curves.
51 patients were operated on isolated TVS (18 annuloplasties and 33 replacements for prosthetic valves).
The study population consisted of a 62.75% of female, with a mean age of 66.07 years (SD 10.57). In the 54% of the cases, the patient was in NYHA functional class of III-IV.
Observed in-hospital mortality was 7.8%. The variables with a strongest association with perioperative mortality were a NYHA functional class of III-IV (0% vs 14.3% mortality; p Fisher = 0.13) and preoperative anemia (OR: 11.1; CI 95%: 1.04-118.6; p = 0.046).
Complete clinical follow-up was achieved in the 94.1% of the study population, with a median follow-up of 26 months (interquartile interval 12-57 months). Overall survival was 90.1%, 84.3%, 80.2%, 75.2% at 1, 2, 3 and 4 years. In the final follow-up, 75% of the patients were in NYHA functional class I-II.
Preoperative NYHA functional class and preoperative anemia are determining factors for early postoperative survival. Medium-term survival and NYHA improvement after isolated TVS are satisfactory.
Tricuspid annulus cinching force under pulmonary hypertensive right ventricle conditions: An ex vivo study
2021, Journal of Biomechanics
This study investigates the force required to reduce or “cinch” the tricuspid annulus under elevated right ventricular pressures, commonly seen in patients with pulmonary hypertension. Tricuspid regurgitation affects 1.6 million Americans. Approximately 43% of patients who undergo tricuspid valve repair to correct tricuspid regurgitation will develop residual pulmonary hypertension, putting them at risk for developing increased right ventricle pressures. Previous studies have quantified the forces required to cinch the tricuspid annulus by only pressurizing the right ventricle, leaving out forces from the pressurized left ventricle and septal wall unaccounted for. This study pressurized both left and right ventricles of 10 porcine hearts to their normal physiological pressures of 110 mmHg and 30 mmHg respectively, then increased right ventricular pressures to mimic moderate and severe pulmonary hypertension. A suture was anchored around the free wall of the tricuspid annulus with the free end attached to a force transducer. The force transducer was mounted on a slider system which pulled the suture at regular intervals. The cinching force on the tricuspid annulus was quantified with each annular reduction by simulating peak systole condition in both ventricles. The data was compared with only the right ventricle pressurized as previous studies did. There were significant differences in required cinching forces with each increase in right ventricular pressure and between trials that pressurized both ventricles versus only the right ventricle, suggesting adoption of this physiologically improved protocol. We also found with increased cinching of the tricuspid annulus, notable changes occur in the mitral annulus.
Functional Regurgitation of Atrioventricular Valves and Atrial Fibrillation: An Elusive Pathophysiological Link Deserving Further Attention
2020, Journal of the American Society of Echocardiography
Citation Excerpt :
A more circular TA shape with a decreased mediolateral/anteroposterior ratio was demonstrated in functional TR (FTR) patients by Fukuda et al.17 using 3D mapping of the TA throughout the cardiac cycle. Loss of 3D annular shape, flattening, and reduced TA contraction (to approximately 15%) were also described in patients with FTR.47,48 Despite increasing evidence of the role played by the RA in determining TA dilatation, this mechanism has been systematically overlooked when considering the pathophysiology and management of FTR.49
In patients with structurally normal atrioventricular valvular apparatus, functional regurgitation of the mitral or tricuspid valves has been attributed mainly to ventricular dilation and/or dysfunction, through a combination of annulus dilation and tethering of the valve leaflets. The occurrence of functional regurgitation of atrioventricular valves in patients with long-standing persistent atrial fibrillation and atrial dilation but normal ventricular size and function has received much less attention, and its peculiar mechanisms still remain to be understood. This distinct form of functional regurgitation (i.e., “atrial functional regurgitation”) may require different treatment and interventional repair approaches than the classical functional regurgitation due to ventricular dilatation and dysfunction (“ventricular functional regurgitation”), and current guideline recommendations do not yet address this distinction. Clarifying the differences in the pathophysiology of atrial functional regurgitation and its management implications is of paramount importance. This review describes briefly the comparative anatomy of mitral and tricuspid apparatus and the pathophysiology and typical echocardiographic features of atrial functional regurgitation compared with ventricular functional regurgitation, as well as the added value of three-dimensional echocardiography as an essential imaging tool to clarify the mechanisms involved in its development.
Post-procedural tricuspid regurgitation predicts long-term survival in patients undergoing percutaneous mitral valve repair
2019, Journal of Cardiology
Citation Excerpt :
Moderate and severe TR was associated with adverse clinical outcome assessed by NYHA functional class and elevated NT-proBNP levels as a sign of neurohumoral response in the organism. Our findings regarding the prevalence of TR in MV disease are in line with previous studies [1,2,17,25]. However, this is the first study to show that post-procedural TR in patients undergoing PMVR is independently associated with long-term survival besides generally known risk factors such as CKD and systolic heart failure [26–28].
Functional tricuspid regurgitation (TR) is frequently present in patients with severe mitral regurgitation and is associated with worse outcome. While percutaneous mitral valve repair (PMVR) is on the increase, the role of TR in those patients is unclear. This study aimed to compare pre- and post-procedural TR and investigated the impact of post-procedural TR and major clinical risk factors on long-term survival in patients undergoing PMVR.
In this retrospective observational cohort study, data from 213 consecutive patients at a tertiary care center undergoing PMVR from 2010 to 2016 were analyzed. Two different groups, dichotomized according to the degree of TR (none/mild and moderate/severe) were compared. Multivariable analyses were performed assessing predictors for long-term survival adjusting for major risk factors.
Following PMVR TR was significantly reduced by at least 1 grade in 23.0% (p = 0.001), while echocardiographic pulmonary pressure was decreased (TR Vmax 3.21 ± 0.49 m/s vs. 2.98 ± 0.53 m/s; p = <0.001). Patients with moderate or severe TR presented with worse New York Heart Association functional class and elevated N-terminal pro B-type natriuretic peptide levels compared to patients with none or mild TR. Median survival time was 1458 days. Proportional hazards model, adjusted for major risk factors, revealed post-procedural TR grade (HR 2.055, CI 1.317–3.206, p = 0.02), severely impaired left ventricular function (HR 3.145, CI 1.199–8.250, p = 0.020), and chronic kidney disease [glomerular filtration rate (GFR) 30–60 ml/min HR 1.917, CI 1.109–3.314, p = 0.020; GFR < 30 ml/min HR 3.969, CI 1.981–7.951, p < 0.001] as independent predictors for long-term survival.
Post-procedural moderate and severe TR predicts worsened long-term survival in patients undergoing PMVR and is associated with adverse clinical outcome. Whether outcome might be improved by interventional reduction of post-procedural TR has to be investigated in the future.
Characteristics and prognosis of patients with significant tricuspid regurgitation
2019, Archives of Cardiovascular Diseases
Citation Excerpt :
The tricuspid valve is often called the “forgotten valve” because its echocardiographical assessment is relatively difficult and the management of patients with tricuspid valve diseases remains poorly defined [1–4].
Severe tricuspid regurgitation (TR) usually remains asymptomatic for a long period, and the diagnosis is often delayed until an advanced stage of right heart failure (RHF). Only a minority of patients are referred for surgery.
To describe the characteristics and prognosis of patients with significant TR, according to aetiology.
Two-hundred and eight consecutive patients with moderate-to-severe (grade III) or severe (grade IV) TR were included from echocardiography reports between 2013 and 2017. Median follow-up was 18 (6–38) months.
Patients (mean age 75 years; 46.6% men) were divided into four groups according to TR aetiology: group 1, primary TR (14.9%); group 2, TR secondary to left heart disease with a history of left heart valve surgery (24.5%); group 3, TR secondary to left heart or pulmonary disease with no history of left valvular surgery (26.5%); and group 4, idiopathic TR (34.1%). During follow-up, 61 patients (29.3%) experienced at least one episode of RHF decompensation requiring hospitalization. Only 11 patients (5.3%) underwent tricuspid valve surgery during follow-up. The 4-year survival was much lower than the expected survival of age- and sex-matched individuals in the general population (56 ± 4% vs. 74%). After adjustment for outcome predictors, patients with idiopathic TR had a higher risk of mortality (adjusted hazard ratio 1.83, 95% confidence interval 1.05–3.21; P = 0.034) compared with other groups.
Moderate-to-severe or severe TR is associated with a high risk of hospitalization for RHF and death at 4 years, and a low rate of surgery. Idiopathic TR is associated with worse outcome than other aetiologies.
L’insuffisance tricuspide (IT) sévère reste le plus souvent asymptomatique pendant une longue période, souvent diagnostiquée avec un retard important au stade d’insuffisance cardiaque droite (IVD) avancée. Seule une minorité de patients est opérée.
–De décrire les caractéristiques ainsi que le pronostic des patients présentant une IT significative selon l’étiologie de l’IT.
Deux cent huit patients consécutifs porteurs d’une IT moyenne (grade III) ou sévère (grade IV) ont été inclus à partir des comptes rendus d’échocardiographie entre 2013 et 2017. Le suivi médian était de 18 (6–38) mois.
Les patients (âge moyen 75 ans; 46,6 % d’hommes) ont été divisés en 4 groupes en fonction de l’étiologie de l’IT: groupe 1, IT primaire (14,9 %); groupe 2, IT secondaire à une cardiopathie gauche avec antécédents de chirurgie valvulaire gauche (24,5 %); groupe 3, IT secondaire à une cardiopathie gauche ou à une maladie pulmonaire sans antécédents de chirurgie valvulaire gauche (26,5 %); et groupe 4, IT idiopathiques (34,1 %). Au cours du suivi, 61 patients (29,3 %) ont présenté au moins une poussée d’IVD nécessitant une hospitalisation. Seuls 11 patients (5,3 %) ont bénéficié d’une chirurgie valvulaire tricuspide au cours du suivi. La survie à 4 ans était très inférieure à la survie attendue dans la population générale appariée pour l’âge et le sexe (56 ± 4 % vs 74 %). Après ajustement aux paramètres associés au pronostic, les patients avec une IT idiopathique avaient un risque de mortalité plus élevé (HR ajusté 1,83, 1,05–3,21; P = 0,034) que les autres groupes.
L’IT de grade III ou IV est associée à un risque élevé d’hospitalisation pour IVD et de décès et à un faible taux de chirurgie à 4 ans. L’IT idiopathique est associée à un plus mauvais pronostic que les autres étiologies.

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¹: All authors take responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation.

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ReviewFunctional tricuspid regurgitation: An underestimated issue

Abstract

Introduction

Section snippets

Definition

Etiology and epidemiology

Anatomical remarks

Pathophysiological mechanisms underlying functional tricuspid regurgitation

Echocardiographic assessment

Clinical presentation, natural history and surgical indications

Surgical procedures and results

Semin Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

Semin Thorac Cardiovasc Surg

J Am Coll Cardiol

Am J Cardiol

Ann Thorac Surg

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

Am Heart J

Am J Cardiol

J Thorac Cardiovasc Surg

J Am Soc Echocardiogr

J Am Coll Cardiol

Ann Thorac Surg

J Am Soc Echocardiogr

Am Heart J

J Thorac Cardiovasc Surg

J Am Coll Cardiol

J Thorac Cardiovasc Surg

Ann Thorac Surg

J Am Soc Echocardiogr

Ann Thorac Surg

Review
Functional tricuspid regurgitation: An underestimated issue