Our most important finding was the low in-hospital mortality among patients undergoing isolated tricuspid valve surgery and significant postoperative improvements in PAP and NYHA functional class. According to a systematic meta-analysis, early mortality in isolated tricuspid valve surgeries is approximately 9%, while late mortality reaches around 27% at four years
6. The early mortality rate of 9.10% observed in our cohort is consistent with these findings, and our mid-term mortality results were more favorable than those reported in the literature.
For many years, the tricuspid valve has been referred to as the "forgotten valve"—often considered only in conjunction with other valve pathologies, and surgical intervention was frequently avoided, whether isolated or combined. This was mainly due to the belief that tricuspid regurgitation (TR) would improve following left-sided valve surgery, as well as the disease's often asymptomatic course, its nonspecific symptoms, and the poor prognosis associated with delayed surgery7.
Once TR becomes symptomatic, it significantly impairs patients’ quality of life and exercise capacity. Leaving patients to cope with progressive TR seems unjustified when compared to the potential benefits of surgical intervention. Our study's acceptable early mortality and highly favorable mid-term outcomes demonstrate that surgical treatment is a far more appropriate approach than continued symptomatic management.
In our cohort, all patients had severe (grade 4) TR at the time of surgery. This suggests that surgery is typically not considered until significant valve dysfunction has occurred and highlights the lack of consensus or guidance regarding intervention in patients with lesser degrees of TR.
Previous studies have shown that delayed surgical intervention in TR patients significantly increases postoperative mortality. Elgharably et al. emphasized that late surgery is associated with irreversible complications such as right ventricular (RV) dysfunction, systemic congestion, and hepatic injury8. In our clinic, the most critical parameter guiding the decision for tricuspid valve surgery is the patient’s tricuspid annular plane systolic excursion (TAPSE) value. Surgical treatment is recommended for patients with TAPSE ≥13 mm, whereas those with lower TAPSE values are generally not considered for surgery. We believe that this selection criterion significantly contributed to our favorable results. Yajima et al. showed that a TAPSE value <15 mm is associated with a high-risk profile and substantially correlates with postoperative mortality9,10. Therefore, it is crucial to intervene before a substantial decline in TAPSE occurs.
In our study, valve repair (ring annuloplasty) was performed in 63.6% of patients, and valve replacement in 36.4%. Literature recommends valve repair when feasible, as the long-term success of bioprosthetic or mechanical valves in the low-pressure right-sided circulation remains controversial11. However, in anatomically unsuitable cases, replacement is unavoidable.
Although a slight decrease in TAPSE was observed postoperatively, the values remained within a range indicating preserved RV function. Numerous studies have emphasized that the right ventricle is more sensitive to volume overload and that RV dysfunction, particularly when caused by TR, is an independent predictor of mortality12. In our study, significant reductions in RV and right atrial (RA) diameters postoperatively, along with preserved TAPSE values, suggest a beneficial effect on mortality and clinical recovery.
A significant reduction in PAP was observed as early as the first postoperative month, which remained stable at the 1-year follow-up. This indicates effective control of pulmonary hypertension following surgery and decreased pressure and volume load on the RV. This finding is consistent with the observations of Mascherbauer et al., who reported that RV afterload and PAP independently influence clinical outcomes regardless of the severity of TR13.
Significant improvements in NYHA class were observed from the first postoperative month, reaching highly substantial levels by the end of the first year. This supports the notion that surgery provides hemodynamic improvement and significantly enhances quality of life. Similar findings have been reported by Dreyfus et al., who demonstrated that NYHA Class III–IV patients improved to Class I–II after surgery11.
The major strength of our study is that it exclusively evaluated patients undergoing isolated tricuspid valve surgery. This eliminated the potential influence of concomitant valve procedures or other interventions on the outcomes. However, limitations include the retrospective study design, the small sample size, and the lack of long-term (>1 year) follow-up data. To more accurately assess the long-term success of right-sided heart surgery, prospective, multicenter studies are needed.
In conclusion, isolated tricuspid valve surgery is a viable treatment option that can be performed with low morbidity and mortality rates in experienced centers. Significant hemodynamic and symptomatic improvements were observed during the one-year follow-up of patients who underwent tricuspid valve surgery. The PAP and NYHA functional class showed marked improvement over this period. Mortality occurred in only one patient.
Therefore, in patients with symptomatic tricuspid regurgitation - whether or not they have undergone prior cardiac surgery - surgical intervention should be considered without unnecessary delay. Randomized prospective studies with larger patient populations are needed to obtain more definitive conclusions.
Funding: The authors received no financial support for the research, authorship, and/or publication of this article.
Conflict of interest: The authors report no proprietary or commercial interest in any product mentioned or concept discussed in this article.
CRediT authorship contribution statement: Mehmet Ali Yürük: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Writing – review & editing, Writing – original draft. Ahmet Coşkun Özdemir: Conceptualization, Methodology; Writing – review & editing, Writing – original draft.
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