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Tricuspid valve repair and tricuspid valve replacement

Overview

Tricuspid valve repair and tricuspid valve replacement are procedures that treat diseases affecting the tricuspid valve.

The tricuspid valve is one of four valves that regulate blood flow through the heart. These valves keep blood flowing in the right direction through the heart.

The tricuspid valve separates one of the heart's two upper and lower chambers (atria and ventricles). With each heartbeat, the atria fill with blood from the body and lungs, and the ventricles contract to pump blood to the lungs and the rest of the body.

As the atria fill to capacity, the tricuspid valve opens to allow blood to flow from the right atrium into the right ventricle. As the ventricles contract, the tricuspid valve shuts tightly to prevent blood from flowing back into the right atrium.

When the tricuspid valve isn't working properly, it can interfere with the proper direction of blood flow and force the heart to work harder to supply the necessary blood to the lungs and the rest of your body.

Tricuspid valve disease is often caused by a heart defect present at birth (congenital heart disease) and may require immediate medical attention in infants.

For others, tricuspid valve disease may not cause any signs or symptoms for many years, if at all. Some people may experience pulsations in the neck, abdominal or chest pain, shortness of breath with activity, fatigue, irregular heartbeat (arrhythmia), heart failure, or sudden cardiac death.

Tricuspid valve repair or tricuspid valve replacement can treat tricuspid valve disease and help restore normal blood flow, reduce symptoms, improve survival in some people and help preserve the function of your heart muscle.

Mayo Clinic's approach
Chambers and valves of the heart

A normal heart has two upper and two lower chambers. The upper chambers, the right and left atria, receive incoming blood. The lower chambers, the more muscular right and left ventricles, pump blood out of your heart. The heart valves, which keep blood flowing in the right direction, are gates at the chamber openings.

Why it's done

Tricuspid valve disease treatment depends on the severity of your condition, whether or not you're experiencing signs and symptoms, and if your condition is getting worse.

For some people with tricuspid valve disease without any symptoms, regular monitoring under a doctor's supervision may be all that's needed.

Types of tricuspid valve disease that may require treatment with tricuspid valve repair or replacement include:

Tricuspid valve regurgitation occurs when the tricuspid valve doesn't close properly and allows blood to flow back into the right atrium when the right ventricle contracts rather than in the normal, one-way direction from the atrium to the ventricle.

The most common cause of tricuspid regurgitation is enlargement of the right ventricle due to other heart or lung disorders, such as heart failure, pulmonary hypertension or emphysema. These conditions make it harder for the blood to flow out of the right ventricle and to the lungs. To compensate for the increased resistance, the tricuspid valve dilates or stretches and can't close completely.

Tricuspid valve regurgitation may also be caused by congenital heart disease (including Ebstein anomaly), injury, infection of the heart valves (infective endocarditis) associated with the use of illicit drugs or bacterial infection (rheumatic fever).

Tricuspid valve stenosis causes the tricuspid valve to become narrowed or obstructed, which makes it more difficult for blood to flow from the right atrium to the right ventricle. Tricuspid valve stenosis may also be accompanied by tricuspid regurgitation or backflow.

Tricuspid valve stenosis may be caused by congenital heart disease, thickening of the valve's closure flaps (leaflets), carcinoid heart disease or as a result of rheumatic fever.

Tricuspid atresia is a type of congenital heart disease that occurs when a baby is born without a tricuspid valve or opening to allow blood to flow from the right atrium to the right ventricle. As a result, the right ventricle is not fully developed and surgery is often needed to increase blood flow to the lungs.

Severe tricuspid valve disease caused by congenital heart disease may require immediate and ongoing medical or surgical care in children. But other types of tricuspid valve disease may be acquired or progress and require medical intervention in adulthood.

Tricuspid valve repair or replacement?

Most tricuspid valve conditions are mechanical problems that cannot be adequately treated with medication alone and will eventually require surgery to reduce symptoms and the risk of complications, such as heart failure.

The decision to repair or replace a damaged tricuspid valve depends on many factors, including:

  • The severity of your tricuspid valve disease
  • Your age and overall health
  • Whether you need heart surgery to correct another heart problem in addition to tricuspid valve disease, such as mitral or aortic valve repair or replacement or coronary artery bypass surgery to treat coronary artery disease, so both conditions can be treated at once

In general, heart valve repair is usually the first choice because it's associated with a lower risk of infection, preserves and optimizes heart function, and may reduce the potential need for long-term use of blood-thinning medications compared with heart valve replacement.

But not all valves can be repaired, and some repaired valves may eventually require replacement. In addition, heart valve repair surgery is often harder to perform successfully than valve replacement surgery.

Your best option will depend on your individual situation, as well as the expertise and experience of your health care team.

Tricuspid valve regurgitation

In tricuspid valve regurgitation, shown in the heart on the right, the valve between the two right heart chambers (right ventricle and right atrium) doesn't close properly. This situation results in blood flowing back into your heart's upper right chamber (right atrium). A normal heart is shown on the left.

Risks

Tricuspid valve repair and tricuspid valve replacement risks vary depending on your health, the type of procedure and the expertise of the health care team. To minimize potential risk, tricuspid valve surgery should generally be performed at a medical center with staff experienced in these procedures and that performs high volumes of tricuspid valve operations.

Risks associated with tricuspid valve repair and tricuspid valve replacement surgery may include:

  • Bleeding
  • Blood clots
  • Valve dysfunction in replacement valves (valve prostheses)
  • Heart rhythm problems
  • Infection
  • Stroke
  • Death

Overall, the long-term survival rates after tricuspid valve repair and tricuspid valve replacement are similar.

How you prepare

Before surgery to have your tricuspid valve repaired or replaced, your doctor and treatment team will explain to you what to expect before, during and after the surgery and potential risks of the surgery.

Discuss with your doctor and treatment team any questions you may have about the procedure.

Before being admitted to the hospital for your surgery, talk to your caregivers about your hospital stay and discuss any help you may need when you return home.

Food and medications

Talk to your doctor about:

  • When you can take your regular medications and whether you can take them before your surgery
  • When you should stop eating or drinking the night before the surgery

Clothing and personal items

Your treatment team may recommend that you bring several items to the hospital including:

  • A list of your medications
  • Eyeglasses, hearing aids or dentures
  • Personal care items, such as a brush, comb, shaving equipment and toothbrush
  • Loosefitting, comfortable clothing
  • A copy of your advance directive or living will
  • Items that may help you relax, such as portable music players or books

During surgery, avoid wearing:

  • Jewelry
  • Eyeglasses
  • Contact lenses
  • Dentures
  • Nail polish

Your body hair will be shaved off at the location where the procedure will take place.

What you can expect

For most tricuspid valve repair and tricuspid valve replacement procedures, you'll receive anesthetics so you won't feel any pain, and you'll be unconscious during the surgery.

You'll also be connected to a heart-lung bypass machine, which keeps blood moving through your body during the procedure.

Tricuspid valve repair

Tricuspid valve repair is traditionally performed via open-heart surgery and opening of the chest bone (sternotomy). Doctors wire the bone back together after the procedure to prevent movement and aid in healing.

Tricuspid valve repair procedures may involve several different types of repair, including:

  • Inserting tissue to patch holes or tears in the flaps (perforated leaflets) that close off the valve
  • Adding support at the base or roots of the valve
  • Separating fused valve leaflets
  • Reshaping or removing tissue to allow the valve to close more tightly
  • Tightening or reinforcing the ring around a valve (annulus) by implanting an artificial ring (annuloplasty)

Cone tricuspid valve repair

A newer type of tricuspid valve repair is known as the cone procedure. The procedure is done to repair leaky tricuspid valves in people with Ebstein anomaly.

In this procedure, surgeons separate the flaps (leaflets) that close off the tricuspid valve from the underlying heart muscle. The leaflets are rotated and reattached to create a circle of leaflet tissue also known as a leaflet cone.

Minimally invasive tricuspid valve repair

Tricuspid valves that can't open fully due to tricuspid valve stenosis may be repaired with surgery or with a less invasive procedure called balloon valvuloplasty or valvotomy. But these procedures are rarely performed because tricuspid stenosis is uncommon.

During the procedure, your doctor inserts a thin, hollow tube (catheter) in a blood vessel, usually in your groin, and threads it to your heart. The catheter has a balloon at its tip that can be inflated to help widen the narrowed tricuspid valve and then deflated for removal.

You're usually sedated but awake during the procedure, and minimally invasive tricuspid valve repair requires a much shorter hospital stay than traditional heart surgery.

Balloon valvuloplasty is often used to treat infants and children with tricuspid valve stenosis. However, the valve tends to narrow again in adults who have had the procedure, so it's usually only performed in adults who are too ill for surgery or who are waiting for a valve replacement. You may need additional procedures to treat the narrowed valve over time.

Tricuspid valve replacement

In this procedure, your doctor replaces the tricuspid valve with a mechanical valve or, much more commonly, a tissue valve made from cow or pig heart tissue (biological tissue valve).

Biological tissue valves eventually need to be replaced, as they degenerate over time. Biological valves require short-term use of blood-thinning medicines for about three to six months. These medications can usually be discontinued at that time unless there is another medical reason to continue use, such as irregular heartbeats.

If you have a mechanical valve, you'll need to take blood-thinning medications for the rest of your life to prevent blood clots or valve thrombosis. Doctors will discuss with you the risks and benefits of each type of valve and discuss which valve may be most appropriate for you.

Tricuspid valve replacement surgery may be performed via traditional open-heart surgery or minimally invasive methods, which involve smaller incisions than those used in open-heart surgery and may include robot-assisted techniques.

A minimally invasive valve-in-valve procedure may also be used to replace an existing replacement tricuspid valve that's failing. In this procedure, a thin plastic tube (catheter) is inserted in a large artery, usually in the groin, and threaded to the heart. Once in place, a new replacement valve is inserted within the existing valve.

Minimally invasive tricuspid valve replacement may be considered if no other heart procedures are necessary and the surgeon and medical center have appropriate skill and expertise. When performed by experienced surgeons and centers, the results are similar to those with traditional open-heart surgery.

After the procedure

You'll generally spend a day or more in the intensive care unit (ICU). You'll be given fluids and medications through intravenous (IV) lines. Other tubes will drain urine from your bladder and drain fluid and blood from your heart and chest. You may be given oxygen.

After the ICU, you'll be moved to a regular hospital room for several days. The time you spend in the ICU and hospital can vary, depending on your condition and procedure.

During your hospital stay, your treatment team will:

  • Watch for signs of infection in your incision sites
  • Periodically check your blood pressure, breathing and heart rate
  • Work with you to manage any pain you experience after surgery
  • Instruct you to walk regularly to gradually increase your activity and do breathing exercises as you recover

Your doctor may give you instructions to follow during your recovery, such as watching for signs of infection in your incisions, properly caring for incisions, taking medications, and managing pain and other side effects after your surgery.

Recovery time depends on your procedure, overall health before the procedure and any complications.

Biological tricuspid valve replacement

In a biological tricuspid valve replacement, a biological or tissue valve replaces the damaged valve.

Incisions in minimally invasive tricuspid valve heart surgery and open-heart surgery

In minimally invasive heart surgery, surgeons access the heart through small cuts (incisions) in the chest, as shown in the top two images. In open-heart surgery, surgeons make a larger incision in the chest, as shown in the bottom image.

Results

After tricuspid valve repair or tricuspid valve replacement surgery, the goal is that you will eventually be able to return to daily activities, such as working, driving and exercise.

You'll still need to take certain medications and attend regular follow-up appointments with your doctor. You may have several tests to evaluate and monitor your condition.

Your doctor and health care team may instruct you to incorporate healthy lifestyle changes — such as physical activity, a healthy diet, stress management and avoiding tobacco use — into your life to reduce the risk of future complications and promote a healthy heart.

Your doctor may recommend that you participate in cardiac rehabilitation — a program of education and exercise designed to help you improve your health and help you recover after heart surgery.

Last updated: March 27th, 2018

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