Tricuspid regurgitation (TR) is a relevant valve disease, although data on treatment outcomes remain limited. Among the primary causes of TR, infective endocarditis is the leading aetiology, accounting for approximately 50% of cases, followed by degenerative changes and valve prolapse. Untreated severe TR may increase patient mortality, which is the main reason why interest in this valve disease has grown, particularly in relation to tricuspid valve repair. Tricuspid valve surgery is recommended in patients with symptomatic severe TR who do not respond adequately to medical therapy.

Tricuspid valve replacement (TVR) is considered only when valve repair is not feasible because of extensive damage or when the valve presents a highly complex malformation. Bioprostheses are usually preferred in young patients to avoid lifelong anticoagulation, despite their potentially lower durability and higher likelihood of reoperation compared with mechanical prostheses. Additionally, mechanical prostheses in the tricuspid position are associated with a higher incidence of thrombosis, favored by the low-flow, low-pressure conditions of the right heart. This results in particularly demanding anticoagulation management and significantly limits the feasibility of future percutaneous treatment options. Unsatisfactory outcomes after TVR may be related to late referral for surgery, with severe right ventricular dysfunction and chronic congestion-related damage to other major organs. With the development of interventional cardiology, the use of transcatheter bioprostheses is increasing; however, these devices are currently unsuitable in cases of massive valve destruction or congenital anomalies. For all these reasons, the emergence of an innovative alternative, such as native valve reconstruction using the patient’s right atrial appendage, is particularly appealing. In theory, because autologous tissue is used, this approach may avoid lifelong anticoagulation and the accelerated structural degeneration associated with bioprostheses.

This case series study was performed at 2 centres, Faghihi and Dena Hospitals, to evaluate outcomes after TVR. A total of 6 patients were selected for this procedure. All had severe TR caused by infective endocarditis or congenital anomaly. Severe TR was defined as a regurgitant jet area greater than 40% of the right atrium or a leaflet tethering distance greater than 8 mm. Patients with a repairable tricuspid valve or multivalvular involvement were excluded.

A total of 6 patients underwent TVR using the right atrial appendage. Three patients had complex valve destruction caused by infective endocarditis, and the other 3 had severe tricuspid valve regurgitation secondary to congenital anomalies. Age ranged from 2 to 57 years, and total operative time ranged from 330 to 390 minutes. Staphylococcus aureus was isolated in all cases of infective endocarditis. No mortality or procedure-related morbidity was reported. All reconstructed valves functioned appropriately and showed no postoperative complications. Echocardiographic follow-up of the reconstructed tricuspid valves demonstrated stable valve function, without regurgitation or significant stenosis.

COMMENTARY:

Conventionally, in the presence of tricuspid valve insufficiency, valve repair should be prioritized in order to preserve the native valve. When repair is not possible, we are forced to implant a prosthesis on the right side of the heart, with the consequent risk of thrombosis despite the use of a bioprosthesis, given the low-pressure environment of the right-sided cardiac chambers.

This study presents an innovative tool for situations in which TVR is required while avoiding the use of artificial materials. It is still too early to assess the reliability of this valve reconstruction technique, but the short-term results are very promising and suggest that this approach could become an additional option when tricuspid valve replacement is unavoidable.

Although concise, the article clearly explains the limitations involved in patient selection and includes a figure outlining the criteria in favour of and against the use of the right atrial appendage. It should be noted that this study included only patients with endocarditis or congenital tricuspid valve anomalies; therefore, its effectiveness in patients with multivalvular disease remains unknown. This is a highly relevant limitation in our field, as isolated tricuspid valve surgery is uncommon. Clearly, longer follow-up and a larger patient cohort are needed to confirm the reliability of this technique.

REFERENCE:

Amirghofran AA, Mirhosseini SA, Narimani-Javid R, Edraki MR, Rafati Navaei M, Mohammadi H, et al. Tricuspid Valve Replacement Using the Right Atrial Appendage Valve: Techniques and 1-Year Results. Interdiscip Cardiovasc Thorac Surg. 2025 Oct 6;40(10):ivaf207. doi: 10.1093/icvts/ivaf207.