Left-sided valve surgery with moderate/severe TR
A 69-year-old patient with severe MR planning mitral valve surgery. Echo also shows moderate-to-severe TR with RA/RV dilation and pulmonary hypertension. This case illustrates why TR must be part of the surgical plan.
Clinical scenario
69-year-old, severe primary MR, mitral valve surgery planned. Echo also shows moderate-to-severe TR, RA/RV dilation, PASP 52 mmHg, annulus estimated 40 mm. How should TR be addressed in surgical planning?
Moderate-to-severe TR with significant annular dilation and pulmonary hypertension in the setting of left-sided valve surgery must be explicitly included in the surgical plan. The decision is individualized — but TR cannot be ignored.
Case presentation
A 69-year-old woman with degenerative mitral valve disease (flail posterior leaflet, P2 segment) has been referred for mitral valve surgery after developing symptoms of dyspnea on moderate exertion. Transthoracic echo confirms severe primary MR with a flail leaflet, EROA 0.55 cm², rvol 65 mL/beat. Mitral valve repair is planned at a cardiac surgery center.
On careful echo review, there is also moderate-to-severe TR: VC 0.65 cm, qualitative grade moderate-to-severe, RA markedly enlarged, RV moderately dilated. RV systolic function mildly reduced (TAPSE 16 mm). PASP 52 mmHg. Tricuspid annulus estimated 40 mm by 2D in the four-chamber view. No device leads. Symptoms: NYHA functional class II-III.
Echo findings summary
| Parameter | Value | Interpretation |
|---|---|---|
| MR severity | Severe (EROA 0.55, rvol 65) | Primary indication for surgery |
| TR VC | 0.65 cm | Moderate-to-severe (approaches severe threshold) |
| Tricuspid annulus | 40 mm | Significantly dilated — threshold for repair consideration |
| PASP | 52 mmHg | Significant pulmonary hypertension |
| RV size | Moderately dilated | Secondary RV remodeling from left-sided disease |
| TAPSE | 16 mm | Mildly reduced RV function |
| Hepatic vein | Systolic blunting (not reversal) | Early congestion sign |
Tool interpretation
TR Severity Tool: TR may be graded as 'discordant TR' or 'likely severe TR' depending on CW Doppler and additional findings. The TR has significant right-heart impact (RV dilation, PH, hepatic blunting).
TR Intervention Navigator with 'left-sided surgery planned: yes': routes to 'left-sided surgery concomitant TR evaluation.' This means TR must be part of the surgical conference discussion.
Clinical reasoning
This patient's TR is secondary — driven by the pulmonary hypertension and RV remodeling from chronic severe MR. After mitral repair, the pulmonary pressure may fall and RV function may recover, potentially reducing TR. However, several factors suggest TR may persist or progress:
- Tricuspid annulus ≥ 40 mm: ACC/AHA VHD 2020 identifies ≥ 40 mm as a criterion supporting concomitant repair at the time of left-sided surgery
- PASP > 50 mmHg: significant pulmonary hypertension may not normalize immediately after MV repair
- Mildly reduced RV function: RV remodeling may not fully reverse after left-sided correction
- Moderate-to-severe TR grade: borderline-severe by VC, with clear right-heart impact
The surgical planning conference should include this TR evaluation. The decision about concomitant tricuspid repair will depend on direct surgical assessment of the tricuspid valve, annular geometry, and the cardiac surgery team's judgment about incremental risk versus benefit.
Intraoperative TEE role
After mitral repair and before chest closure, intraoperative TEE provides a critical assessment: residual TR under reduced anesthetic-related afterload, tricuspid annular size during CPB, and RV function after left-sided repair. If significant TR persists on CPB, the cardiac surgery team may proceed to concomitant tricuspid annuloplasty.
Teaching points
- TR coexisting with left-sided valve surgery must be explicitly evaluated — TR grade alone does not determine whether concomitant repair is appropriate.
- Tricuspid annular dilation (≥ 40 mm) and persistent pulmonary hypertension (PASP > 50 mmHg) increase the likelihood that TR will not resolve after left-sided repair alone.
- The TR Intervention Navigator routes 'left-sided surgery planned' to concomitant TR evaluation — not to automatic repair recommendation. The surgical team makes the final decision.
- Intraoperative TEE after left-sided repair on CPB is the definitive evaluation for residual TR requiring concomitant intervention.
- TR grading under anesthetic conditions may differ from pre-surgical echo — loading conditions, rhythm, and vasodilation all affect TR severity acutely.
Apply this in practice
Use the TR Intervention Navigator — enter 'left-sided surgery planned: yes' to evaluate the surgical planning context.
Open TR Intervention Navigator