Tricuspid Valve Surgery at Cleveland Clinic
Physicians in Cleveland Clinic’s Sydell and Arnold Miller Family Heart & Vascular Institute perform the largest number of valve procedures in the United States. They performed more than 2,900 in 2010, and more than 2100 of these were first-time valve operations; the others were reoperations.
Our cardiac surgeons are experienced in treating patients with complex heart valve problems, multiple valve problems and valve disease in combination with other types of heart disease. They also are experienced in treating high-risk patients, including the elderly, those with other medical conditions and patients who are obese.
What is Tricuspid Valve Disease?
The tricuspid valve is located between the heart’s right upper chamber (atrium) and lower chamber (ventricle). Its role is to make sure blood flows the correct way through the heart, from the right atrium down to the ventricle. The tricuspid valve has three leaflets, or flaps, that control blood flow and direction.
In some people, this valve does not function correctly, and they are said to have tricuspid valve disease. Tricuspid valve disease is rare compared with other types of valve disease. The most common form of tricuspid valve disease is tricuspid stenosis, which means the valve leaflets are stiff and do not open all the way. This makes the valve narrow and restricts the blood flow. Another form of valve disease is tricuspid regurgitation. Patients with this condition have leaflets that do not close all the way and blood leaks backwards across the valve instead of flowing into the ventricle. These conditions cause the heart to pump harder to move blood through the body.
How is Tricuspid Valve Disease Treated?
If you have mild tricuspid valve disease, your physician may prescribe medications to treat the symptoms. These medications may include drugs to control heart failure or to manage an irregular heart rhythm. The goal of nonsurgical treatment is to prevent further damage to the heart.
If the valve condition is severe or gets worse over time, you’ll need surgery to repair or replace the faulty valve.
Having tricuspid valve surgery while the disease is still in its early stages may prevent more severe, permanent heart damage. Your cardiologist will talk with you about the benefits and risks of surgical procedures and help you decide at what point you should have surgery. If an echocardiograph shows that the disease is severe and involves other heart valves, early surgery is usually recommended.
There are two kinds of valve surgery:
- Valve repair
- Valve replacement
Valve repair is the preferred surgical treatment for tricuspid valve disease. Tricuspid valve repair can be done alone or in combination with treatments for other heart problems.
Advantages of Repair
Repair has a number of advantages over valve replacement:
- Longer survival
- Overall better results
- Lower risk of complications, such as stroke or infection
- No need to take anticoagulant (blood-thinning) for the rest of the patient’s life
The reason for these advantages is that repairing the valve is less disruptive to the heart’s physical structure and the valve is the patient’s own tissue so it is less likely to get infected or cause blood clots. Patients who have a valve replacement need to take lifelong blood thinners to prevent stroke.
Traditional Valve Repair
Valve repair is a technically challenging procedure, and the success and outcome depend on the surgeon’s experience and skill, as well as the condition of the patient’s valve. This is why you should have the procedure performed by a surgeon with experience in valve repair at a hospital where many of these procedures are performed each year.
Traditional tricuspid valve repair is an open-heart procedure. During the surgery, your heart is stopped so the surgeon can work on a still heart. A heart-lung bypass machine is used to circulate your blood through your body. At the Miller Family Heart & Vascular Institute, the heart surgeon and cardiologist often use transesophageal echocardiography during the operation to check the valve’s function before and after surgery. A surgeon who is skilled in heart valve repair can perform several different repair procedures to separate leaflets that have fused, repair leaflets that are torn and reshape parts of the valve, depending on the valve problem.
Edwards MC 3 Annuloplasty System
These techniques include:
Annulus support involves the use of a tissue-based or synthetic ring to reinforce the annulus, which is the ring of tissue at the base of the valve leaflets. This procedure restores the annulus to right size and shape and allows the leaflets to open and close completely.
Tricuspid valve repair using an annuloplasty ring is the preferred surgical approach for tricuspid regurgitation and may be performed for primary tricuspid disease or for combined cases with other valve surgery (mitral, aortic).
Research has shown that the Rigid prosthetic ring annuloplasty provides better long term outcomes 2
Leaflet patching is used to treat tricuspid valve regurgitation. The surgeon repairs the torn leaflet with a patch to correct the leaking valve and eliminate blood backflow.
Tricuspid Valve Replacement
Although most patients have their valve repaired, some patients need the valve replaced. Your surgeon will determine which treatment is the best for you.
During valve replacement, the surgeon removes the patient's original valve and replaces it with either a biologic (tissue-based) or mechanical valve.
Biologic valves are made of pig (porcine), cow (bovine) or human (allograft or homograft) tissue. They last 15 to 20 years and do not require the patient to take anticoagulant (blood-thinning) medication for the rest of their life.
Lanyard and template handle assists with placement of ring
Mechanical valves are made of metal or carbon surrounded with a polyester knit fabric-covered ring. These valves last longer than biologic valves and require lifelong therapy with blood-thinning medication to reduce the risk of blood clots and stroke.
At the Miller Family Heart & Vascular Institute, 85 percent of valve replacement procedures in 2010 involved biologic valves.
Minimally Invasive and Robotically Assisted Valve Surgery
Minimally invasive surgery is an option for many patients with tricuspid valve disease. While traditional valve surgery is performed through a 6 – 8 inch incision through the breastbone (sternum), a minimally invasive approach may include:
- Smaller 3 inch incision through the breastbone
- Robotically assisted approach, which involves several small incisions in the chest wall.
- Right thoracotomy approach, which involves a small incision on the right side in between the rib cage
Anatomically correct design conforms to the 3-D tricuspid valve opening.
The benefits of minimally invasive surgery are:
- Reduced blood loss
- Reduced surgical trauma
- Shorter hospital stay
Cleveland Clinic heart surgeons have helped develop many of the minimally invasive surgical techniques used in valve surgery.
Your surgeon will evaluate your overall medical condition, your heart’s anatomy and function, and the severity and extent of your valve disease to determine if you are a candidate for a minimally invasive valve procedure.
Complex Tricuspid Valve Surgery
Patients with tricuspid valve disease often have other heart conditions, such as mitral or aortic valve disease, an abnormal heart rhythm (atrial fibrillation) or have had previous heart surgery, such as a coronary bypass, which is causing problems with the tricuspid valve.
Cleveland Clinic surgeons are experienced in performing tricuspid valve surgery with other procedures, such as those to treat other types of valve repair and abnormal heart rhythms. The surgeons are also experienced in operating on patients with infected heart tissue (endocarditis).
What Happens After Surgery?
The average hospital stay is 5 days after tricuspid valve surgery. The recovery process continues at home. Most patients return to all of their normal activities within 3 to 4 months after surgery.
After you have fully recovered, your quality of life should be as good as or better than it was before your surgery. You probably will have few, if any, restrictions on your activities.
Your chance of long-term success is good. Statistics show up to a 95% chance that after a valve is repaired, no further intervention is needed for 10 to 20 years; however, this time is shorter if the repair was complex.
For more information about tricuspid valve disease treatments:
- Navia JL, Brozzi NA, Klein AL, Ling LF, Kittayarak C, Nowicki ER, Batizy LH, Zhong J, Blackstone EH. Moderate Tricuspid Regurgitation With Left-Sided Degenerative Heart Valve Disease: To Repair or Not to Repair? Ann Thorac Surg. 2011 Nov 15. [Epub ahead of print]
- Jose L. Navia, Edward R. Nowicki, Eugene H. Blackstone, Nicolas A. Brozzi, Daniel E. Nento, Fernando A. Atik, Jeevanantham Rajeswaran, A. Marc Gillinov, Lars G. Svensson, and Bruce W. Lytle. Surgical management of secondary tricuspid valve regurgitation: Annulus, commissure, or leaflet procedure? J. Thorac. Cardiovasc. Surg., June 2010; 139: 1473 - 1482.