Tricuspid Regurgitation, Isn't It Time to Look Around the Valve Rather Than the Valve Itself?

It was not until a couple of decades ago that the tricuspid valve has received attention to clinicians. Based on anecdotal experience in patients with Fontan physiology 1) and also in a case of a patient without tricuspid valve because of endocarditis, 2) cli-nicians have had a misconception that the tricuspid valve may be a 'rudimentary' or even an 'unnecessary' valve in the heart. Nowadays these misconceptions have been disputed by firm clinical observations that the severity of the tricuspid regurgi-tation (TR) is an independent predictor of mortality. 3) Although the event rates are still high with surgical correction of severe TR, 4)5) it is equally well-known that TR is a correctable disease and provided that patients are carefully selected, 5) surgical correction may be a life-saving procedure. Furthermore, the rate of significant early morbidity and mortality after surgical correction has dropped to as less as 2% in certain experienced centers. 6) Therefore, the next legitimate question regarding TR is what factors are associated with the development of TR and consequently, which patients need intensive surveillance. It has been shown in previous papers that the morphology and certain changes in the valve itself leads to significant TR. 7) Although previous papers have looked into the clinical significance of TR, 8) only a few articles have touched on the impact of the surrounding structures/chambers on the development of TR. 9) This is important because a significant majority of TR is functional TR. Furthermore, the majority of papers have only focused on TR secondary to significant concomitant left-sided valve disease. 10)11) The interesting article by Park et al. 12) have brought to us an interesting suggestion to this important and yet, unresolved question. Although it is well known that atrial fibrillation is an important contributor to the development of significant TR, 10)11) geometric or functional parameters that begets TR has not been investigated enough in previous papers, especially in isolated atrial fibrillation patients such as that in the paper in this issue of the Journal. What the authors have found in their 89 atrial fibrillation patients with a variety of TR degree is that persistent atrial fi-brillation, tricuspid annular diameter and the tenting height of the tricuspid valve are the significant determinants of significant TR. Perhaps a more interesting finding was that structures that surround the tricuspid valve, that is the right atrium (RA) and the right ventricle (RV), are significantly associated …