The importance of tricuspid valve structure and function in the surgical treatment of rheumatic mitral and aortic disease

A significant proportion of individuals with rheumatic disease have tricuspid valve involvement which may be clinically important and alter the medical or surgical approach to treatment. Therefore 50 patients with rheumatic left-sided valvular lesions who were referred for operative treatment were studied. Thirty patients had angiographically significant tricuspid regurgitation (group I) and 20 had a competent tricuspid valve (group II). Pre-operative cardiac assessment included Doppler echocardiography and contrast ventriculography. Patients with tricuspid regurgitation more commonly had mitral valve disease or combined mitral and aortic valve lesions, (P <0.001) and were more likely to have atrial fibrillation than those without tricuspid regurgitation (P <0.001). Pulmonary arterial systolic and mean right atrial pressures were higher in group I (both P <0.01). A close relationship was found between the angiographic and Doppler assessment of the degree of tricuspid regurgitation (P <0.01). Doppler-derived measurement of the right ventricular-right atrial systolic pressure difference correlated well with the systolic trans-tricuspid pressure difference measured at cardiac catheterization (y=0.7x+22, r=0.67, P<0.001) and the pulmonary arterial systolic pressure (y=0.8x+27, r=0.71, P<0.001). Rheumatic involvement of the tricuspid valve identified by pre-operative echocardiography was confirmed in five patients at surgery. Of the 13 patients with functional tricuspid regurgitation at operation, only two had been diagnosed as having organic disease by echocardiography. Furthermore, in all 18 cases where Doppler suggested grade 3 or 4+ tricuspid regurgitation, surgical repair or replacement of the valve was performed. Right ventricular ejection fraction <45% was associated with severe tricuspid regurgitation (grade 3 and 4+) while right ventricular ejection fraction >45% was associated with grade 1 and 2 + tricuspid regurgitation.These findings demonstrate that abnormalities of the tricuspid valve, whether functional or due to rheumatic involvement, are frequent in young individuals with left-sided rheumatic heart disease. The pathogenesis and severity of tricuspid disease is readily identified by Doppler echocardiography. The tricuspid valve should be carefully evaluated by Doppler echocardiography in patients being considered for surgical treatment of rheumatic valve disease, because the results can importantly influence the surgical approach. © 1992 The European Society of Cardiology.