Functional or secondary tricuspid regurgitation (STR) is the most frequent etiology of tricuspid valve pathology in Western countries. Surgical tricuspid repair has been avoided for years, because of the misconception that tricuspid regurgitation should disappear once the primary left-sided problem is treated; this results in a large number of untreated patients with STR. Over the past few years, many investigators have reported evidence in favor of a more aggressive surgical approach to STR. Consequently, interest has been growing in the physiopathology and treatment of STR. The purpose of this review is to explore the anatomical basis, pathophysiology, therapeutic approach, and future perspectives with regard to the management of STR.

The operative mortality of surgical treatment of paravalvular leak is still high. Long-term outcomes remain suboptimal in these challenging patients, especially in the presence of multiple previous cardiac operations and associated co-pathologies. These results support the importance of alternative therapeutic options.

Moderate-to-severe tricuspid regurgitation (TR) affects ∼1.6 million patients in the USA, of whom only 8000 undergo tricuspid surgery annually; this results in an extremely large number of untreated patients with significant TR. Therefore, there is a large unmet clinical need for patients with severe TR who are not referred for conventional surgery, mainly due to expected high surgical risk. Percutaneous procedures are an attractive alternative to surgery for patients deemed to be high-risk surgical candidates. Whereas over the past few years, the development and clinical use of percutaneous approaches to the aortic valve and mitral valve have been widespread, few data are available about the feasibility and the efficacy of the percutaneous tricuspid valve treatment. This review will explore the available technologies, which are today under evaluation and the preliminary clinical results.

A transcatheter closure via a surgical TAp approach appears to be a safe and effective therapeutic option in selected high-risk patients with PVL and is associated with a lower hospital mortality than surgical treatment, in spite of higher predicted risk. Long-term survival remains suboptimal in these challenging patients.

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Sternotomy is considered to be the gold standard incision in cardiac surgery, resulting in low failure rates and excellent proven long-term outcomes. It can also be used in thoracic surgery for mediastinal, bilateral pulmonary or lower trachea and main stem bronchus surgery. Sternotomy has to be performed properly to avoid short- and long-term morbidity and mortality. The surgical technique is well established and certain principles are recognized to be crucial to minimize complications. The identification of the correct landmarks, midline tissue preparation, osteotomy with the avoidance of injury to underlying structures like pleura, pericardium, innominate vein, brachiocephalic artery and ectatic ascending aorta, and targeted bleeding control are important steps of the procedure. As important as the performance of a proper sternotomy is a correct sternal closure. An override or shift of the sternal edges has to be avoided by placing the wires at a proper distance from each other without injuring the thoracic pedicle. The two sternal halves have to be tightly re-approximated to facilitate healing of the bone and to avoid instability, which is a risk factor for wound infection. With a proper performance of sternotomy and sternal closure, instability and wound infections are rare and depend on patient-related risk factors.

The echocardiographic-fluoroscopic fusion imaging is a new imaging system which has recently become available, with the proposal to facilitate catheters and device navigation during catheter-based structural heart disease interventions. Several reports have described the early developments and the first clinical experiences, but literature focusing on the practical applications of fusion imaging technology to mitral valve transcatheter interventions, and on its potential advantages and current limitations, is still limited. In this review, we, therefore, describe the role of this novel imaging system during Mitraclip, Cardioband, and paravalvular leak closure interventions. The technical principles and the fluoroscopic anatomy of the interatrial septum and mitral valve are also described.

Tricuspid valve replacement (TVR) is associated with high mortality and morbidity. Frequently, TVR is performed in critically ill patients with high frequency of re-intervention. We analyzed our experience in TVR focusing on predicting risk factors, mid-term survival and quality of life assessed with a Short-Form 36 Health Survey (SF-36) questionnaire. Between January 1992 and May 2007, 81 consecutive patients underwent TVR (54 re-interventions, 66.7%; 46 procedures, associated with a left-sided operation, 56.8%). There were 59 females (73%) with a mean age of 59.3+/-11.6 years. The most prevalent etiology was rheumatic fever (61.7%). Pulmonary hypertension was present in 64%. Mean left ventricle ejection fraction (LVEF) was 56.6% and mean right ventricle ejection fraction (RVEF) was 48.1%. All but four patients (4.9%) received a bio-prosthesis. Hospital mortality was 9.88%. The mean follow-up was 61+/-42 months. Survival was 68% at five years. Univariate predictors of hospital mortality were atrial fibrillation (AFib) (P<0.01), associated procedures on the left heart (P=0.025) and preoperative chronic right heart failure symptoms (P<0.01). At follow-up: 10.8% of patients had a pace-maker (PM) induced rhythm; the mean SF-36 score was 51.1+/-4.8 (range 59-38). Age (P=0.015), associated procedures (P=0.024) and previous cardiovascular surgery (P=0.015) were univariate predictors of the SF-36 score. At a multivariate analysis LVEF, venous congestion and pulmonary artery pressures (PAPs) were related with a SF-36 score.