Illustration of tricuspid valve repair after mitral valve surgery symbolizing heart chamber healing.

Second Chance Heart: Navigating Tricuspid Valve Repair After Mitral Valve Surgery

Jordan Keane in Health & Wellness November 2025 • 4 min read.

"Discover the complexities, risks, and innovative techniques in tricuspid valve repair following mitral valve surgery, offering hope for improved heart health."

Tricuspid valve regurgitation (TR) often arises as a secondary issue in individuals who have previously undergone surgery for left-sided valve failure, particularly concerning the mitral valve. In these cases, the leaflets and chordae of the tricuspid valve itself are typically healthy. The problem stems from the tricuspid annulus dilating due to chronic volume and pressure overload affecting the right ventricle.

Over time, the three-dimensional structure of the tricuspid annulus can flatten, and the tricuspid valve may become more restrictive due to leaflet tethering, which is a result of the right ventricle’s increasing dilation. It was once believed that addressing the mitral valve issue would resolve the tricuspid valve problems. However, it's now understood that tricuspid valve regurgitation can persist and even worsen years after mitral valve surgery, necessitating direct intervention.

The European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS) recommend considering tricuspid valve surgery at the time of left-sided surgery in patients with severe secondary TR and even in those with mild to moderate TR if the annulus is dilated.

When is Tricuspid Valve Surgery Necessary After Mitral Valve Repair?

Illustration of tricuspid valve repair after mitral valve surgery symbolizing heart chamber healing.

Current guidelines suggest that tricuspid valve surgery should be considered if, after previous left-sided valve surgery, a patient experiences severe TR accompanied by symptoms or progressive right-ventricular dilatation/dysfunction. This recommendation stands, provided there is no concurrent left-sided valve dysfunction, severe dysfunction in either ventricle, or advanced pulmonary vascular disease.

Often, patients who need tricuspid valve re-intervention present quite late, sometimes years after their initial mitral valve surgery. This delay can lead to an extensively dilated and thinned right ventricle. These patients frequently have additional health issues related to the TR, such as cardiac-related congestion, liver cirrhosis, ascites, renal failure, or esophageal varices. These complications can significantly affect the patient's prognosis, requiring careful preoperative evaluation and preparation.

Surgical Risk: Tricuspid valve surgery following previous cardiac surgery is considered high-risk, with reported early mortality rates varying widely.
Post-Operative Challenges: Post-surgery, the right ventricle must adapt to handling pressure rather than volume overload, a condition it typically tolerates less effectively than the left ventricle.
Contraindications: Severe dysfunction in either the right or left ventricle, unresolved left-sided valve issues, and severe pulmonary hypertension may rule out redo TV surgery.

Accessing the tricuspid valve during reoperation can be challenging. While median sternotomy (a traditional chest incision) can be risky due to potential injury to the thin right ventricle, a minimally invasive approach through the right side may be feasible if there are no extensive pleural adhesions. This approach involves cannulation of the femoral artery and vein, as well as the right jugular vein, to establish cardiopulmonary bypass. Balloon catheters may be used to block the vena cavae, achieving complete bypass without clamping or snaring vessels.

Looking Ahead: Preventing Future Tricuspid Valve Issues

Ultimately, it’s critical to consider whether concomitant tricuspid valve surgery should be more routinely performed during mitral valve procedures in patients with dilated tricuspid valve annuli. Further research is needed to fully understand why TR progresses in some individuals years after mitral valve correction. Studies suggest that TR associated with functional or ischemic mitral regurgitation may result from combined left and right heart disease, with volume backflow as a secondary factor. The goal is to identify and address tricuspid valve issues proactively, improving long-term outcomes and quality of life for patients with heart valve disease.

About this Article -

This article was crafted using a human-AI hybrid and collaborative approach. AI assisted our team with initial drafting, research insights, identifying key questions, and image generation. Our human editors guided topic selection, defined the angle, structured the content, ensured factual accuracy and relevance, refined the tone, and conducted thorough editing to deliver helpful, high-quality information.See our About page for more information.

This article is based on research published under:

DOI-LINK: 10.1055/s-0037-1605362, Alternate LINK

Title: Tricuspid Valve Repair After Previous Mitral Valve Surgery

Subject: Cardiology and Cardiovascular Medicine

Journal: The Thoracic and Cardiovascular Surgeon

Publisher: Georg Thieme Verlag KG

Authors: Martin Misfeld, Martin Haensig, Piroze Davierwala, Friedrich Mohr, Bettina Pfannmueller

Published: 2017-08-15

Everything You Need To Know

Why does tricuspid valve regurgitation often develop after mitral valve surgery, even if the tricuspid valve itself appears healthy?

Tricuspid valve regurgitation often emerges after surgery addressing left-sided valve issues, especially involving the mitral valve. Though the tricuspid valve leaflets and chordae might be healthy, the tricuspid annulus dilates due to sustained volume and pressure overload on the right ventricle. This contrasts with primary TR, where the valve itself is diseased. Over time, the tricuspid annulus flattens, potentially restricting the valve due to leaflet tethering from the right ventricle's dilation. Addressing the mitral valve might not always resolve these secondary tricuspid valve problems, sometimes requiring direct intervention on the tricuspid valve.

Under what specific conditions is tricuspid valve surgery deemed necessary following a previous mitral valve repair or replacement?

Guidelines suggest considering tricuspid valve surgery if, following left-sided valve surgery, a patient develops severe tricuspid regurgitation alongside symptoms or progressive right-ventricular dilatation or dysfunction. This is contingent on the absence of concurrent left-sided valve dysfunction, severe dysfunction in either ventricle, or advanced pulmonary vascular disease. The European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS) recommend considering tricuspid valve surgery at the time of left-sided surgery in patients with severe secondary TR and even in those with mild to moderate TR if the annulus is dilated.

What are the potential consequences of delaying tricuspid valve re-intervention after initial mitral valve surgery, and how do these complications impact patient outcomes?

Patients needing tricuspid valve re-intervention often present late, years after their initial mitral valve surgery, leading to an extensively dilated and thinned right ventricle. Accompanying issues like cardiac-related congestion, liver cirrhosis, ascites, renal failure, or esophageal varices can arise from the tricuspid regurgitation, affecting the patient's prognosis. This necessitates thorough preoperative evaluation and preparation to manage these complications before addressing the tricuspid valve.

What are the primary contraindications that might prevent a patient from undergoing a second tricuspid valve surgery after a mitral valve procedure?

Severe dysfunction in either the right or left ventricle, unresolved left-sided valve problems, and severe pulmonary hypertension might preclude redo tricuspid valve surgery. These contraindications stem from the increased surgical risk and the challenges the right ventricle faces in adapting to pressure rather than volume overload post-surgery. Post-Operative Challenges: Post-surgery, the right ventricle must adapt to handling pressure rather than volume overload, a condition it typically tolerates less effectively than the left ventricle.