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Tricuspid regurgitation (TR) is a common finding.  TR is mostly a trace or mild regurgitation and usually has no symptoms when [[pulmonary hypertension]] and [[heart failure]] are absent.<ref name="pmid15013122">{{cite journal| author=Nath J, Foster E, Heidenreich PA| title=Impact of tricuspid regurgitation on long-term survival. | journal=J Am Coll Cardiol | year= 2004 | volume= 43 | issue= 3 | pages= 405-9 | pmid=15013122 | doi=10.1016/j.jacc.2003.09.036 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15013122  }} </ref>  However, moderate and severe TR are associated with increased morbidity and mortality.  The more severe the TR, the worse the prognosis.<ref name="pmid15013122">{{cite journal| author=Nath J, Foster E, Heidenreich PA| title=Impact of tricuspid regurgitation on long-term survival. | journal=J Am Coll Cardiol | year= 2004 | volume= 43 | issue= 3 | pages= 405-9 | pmid=15013122 | doi=10.1016/j.jacc.2003.09.036 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15013122  }} </ref>
Tricuspid regurgitation (TR) is a common finding.  TR is mostly a trace or mild regurgitation and usually has no symptoms when [[pulmonary hypertension]] and [[heart failure]] are absent.<ref name="pmid15013122">{{cite journal| author=Nath J, Foster E, Heidenreich PA| title=Impact of tricuspid regurgitation on long-term survival. | journal=J Am Coll Cardiol | year= 2004 | volume= 43 | issue= 3 | pages= 405-9 | pmid=15013122 | doi=10.1016/j.jacc.2003.09.036 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15013122  }} </ref>  However, moderate and severe TR are associated with increased morbidity and mortality.  The more severe the TR, the worse the prognosis.<ref name="pmid15013122">{{cite journal| author=Nath J, Foster E, Heidenreich PA| title=Impact of tricuspid regurgitation on long-term survival. | journal=J Am Coll Cardiol | year= 2004 | volume= 43 | issue= 3 | pages= 405-9 | pmid=15013122 | doi=10.1016/j.jacc.2003.09.036 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15013122  }} </ref>


==Natural History==
==Natural History, Complications, and Prognosis==
 
=== Natural History ===
 
 
 
TR is a common valvular abnormality usually presenting with no symptoms when [[pulmonary hypertension]] and [[heart failure]] are absent.<ref name="pmid15013122">{{cite journal| author=Nath J, Foster E, Heidenreich PA| title=Impact of tricuspid regurgitation on long-term survival. | journal=J Am Coll Cardiol | year= 2004 | volume= 43 | issue= 3 | pages= 405-9 | pmid=15013122 | doi=10.1016/j.jacc.2003.09.036 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15013122  }} </ref> When symptoms are present, they develop progressively. TR might not be recognised clinically until fairly late in its natural history.<ref name="pmidPMID: 27048553">{{cite journal| author=Rodés-Cabau J, Taramasso M, O'Gara PT| title=Diagnosis and treatment of tricuspid valve disease: current and future perspectives. | journal=Lancet | year= 2016 | volume= 388 | issue= 10058 | pages= 2431-2442 | pmid=PMID: 27048553 | doi=10.1016/S0140-6736(16)00740-6 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27048553  }} </ref> Patients with significant TR may remain asymptomatic, despite impaired right ventricular function.<ref name="pmidpmidPMID:_26022823">{{cite journal| author=Dreyfus GD, Martin RP, Chan KM, Dulguerov F, Alexandrescu C| title=Functional tricuspid regurgitation: a need to revise our understanding. | journal=J Am Coll Cardiol | year= 2015 | volume= 65 | issue= 21 | pages= 2331-6 | pmid=pmidPMID:_26022823 | doi=10.1016/j.jacc.2015.04.011 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26022823  }} </ref> Significant degrees of TR have been noted with the onset of atrial fibrillation, especially in older patients above 75 years of age.<ref name="pmidPMID: 27048553" /> TR can be present in isolation or associated with other medical conditions. TR commonly occurs among patients with mild/moderate [[mitral regurgitation]] (MR) or [[mitral stenosis]].  Approximately 30-50% of patients with severe [[MR]] have significant secondary TR.<ref name="pmidpmidPMID:_26022823" /><ref name="pmidPMID: 12228791">{{cite journal| author=Koelling TM, Aaronson KD, Cody RJ, Bach DS, Armstrong WF| title=Prognostic significance of mitral regurgitation and tricuspid regurgitation in patients with left ventricular systolic dysfunction. | journal=Am Heart J | year= 2002 | volume= 144 | issue= 3 | pages= 524-9 | pmid=PMID: 12228791 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12228791  }} </ref><ref name="pmid3657251">{{cite journal| author=Cohen SR, Sell JE, McIntosh CL, Clark RE| title=Tricuspid regurgitation in patients with acquired, chronic, pure mitral regurgitation. II. Nonoperative management, tricuspid valve annuloplasty, and tricuspid valve replacement. | journal=J Thorac Cardiovasc Surg | year= 1987 | volume= 94 | issue= 4 | pages= 488-97 | pmid=3657251 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3657251  }} </ref> Severe TR with [[pulmonary hypertension]]/[[right heart failure|right ventricular dysfunction]] has a worse prognosis and frequently requires surgical intervention. Isolated [[mitral valve surgery]] for mitral valve abnormalities is associated with no improvement of TR in the majority of patients.<ref name="pmid7934109">{{cite journal| author=Sagie A, Schwammenthal E, Palacios IF, King ME, Leavitt M, Freitas N et al.| title=Significant tricuspid regurgitation does not resolve after percutaneous balloon mitral valvotomy. | journal=J Thorac Cardiovasc Surg | year= 1994 | volume= 108 | issue= 4 | pages= 727-35 | pmid=7934109 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7934109  }} </ref> It is also not uncommon to have residual TR following isolated left-sided valve surgery, especially when some preoperative risk factors are present.<ref name="pmid25402599">{{cite journal| author=Zhu TY, Min XP, Zhang HB, Meng X| title=Preoperative risk factors for residual tricuspid regurgitation after isolated left-sided valve surgery: a systematic review and meta-analysis. | journal=Cardiology | year= 2014 | volume= 129 | issue= 4 | pages= 242-9 | pmid=25402599 | doi=10.1159/000367589 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25402599  }} </ref> Tricuspid valve surgery at the time of left-sided valvulopathy decreases the rate of post-operative residual tricuspid regurgitation.<ref name="pmid9576162">{{cite journal| author=Tager R, Skudicky D, Mueller U, Essop R, Hammond G, Sareli P| title=Long-term follow-up of rheumatic patients undergoing left-sided valve replacement with tricuspid annuloplasty--validity of preoperative echocardiographic criteria in the decision to perform tricuspid annuloplasty. | journal=Am J Cardiol | year= 1998 | volume= 81 | issue= 8 | pages= 1013-6 | pmid=9576162 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9576162  }} </ref>
TR is a common valvular abnormality usually presenting with no symptoms when [[pulmonary hypertension]] and [[heart failure]] are absent.<ref name="pmid15013122">{{cite journal| author=Nath J, Foster E, Heidenreich PA| title=Impact of tricuspid regurgitation on long-term survival. | journal=J Am Coll Cardiol | year= 2004 | volume= 43 | issue= 3 | pages= 405-9 | pmid=15013122 | doi=10.1016/j.jacc.2003.09.036 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15013122  }} </ref> When symptoms are present, they develop progressively. TR might not be recognised clinically until fairly late in its natural history.<ref name="pmidPMID: 27048553">{{cite journal| author=Rodés-Cabau J, Taramasso M, O'Gara PT| title=Diagnosis and treatment of tricuspid valve disease: current and future perspectives. | journal=Lancet | year= 2016 | volume= 388 | issue= 10058 | pages= 2431-2442 | pmid=PMID: 27048553 | doi=10.1016/S0140-6736(16)00740-6 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27048553  }} </ref> Patients with significant TR may remain asymptomatic, despite impaired right ventricular function.<ref name="pmidpmidPMID:_26022823">{{cite journal| author=Dreyfus GD, Martin RP, Chan KM, Dulguerov F, Alexandrescu C| title=Functional tricuspid regurgitation: a need to revise our understanding. | journal=J Am Coll Cardiol | year= 2015 | volume= 65 | issue= 21 | pages= 2331-6 | pmid=pmidPMID:_26022823 | doi=10.1016/j.jacc.2015.04.011 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26022823  }} </ref> Significant degrees of TR have been noted with the onset of atrial fibrillation, especially in older patients above 75 years of age.<ref name="pmidPMID: 27048553" /> TR can be present in isolation or associated with other medical conditions. TR commonly occurs among patients with mild/moderate [[mitral regurgitation]] (MR) or [[mitral stenosis]].  Approximately 30-50% of patients with severe [[MR]] have significant secondary TR.<ref name="pmidpmidPMID:_26022823" /><ref name="pmidPMID: 12228791">{{cite journal| author=Koelling TM, Aaronson KD, Cody RJ, Bach DS, Armstrong WF| title=Prognostic significance of mitral regurgitation and tricuspid regurgitation in patients with left ventricular systolic dysfunction. | journal=Am Heart J | year= 2002 | volume= 144 | issue= 3 | pages= 524-9 | pmid=PMID: 12228791 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12228791  }} </ref><ref name="pmid3657251">{{cite journal| author=Cohen SR, Sell JE, McIntosh CL, Clark RE| title=Tricuspid regurgitation in patients with acquired, chronic, pure mitral regurgitation. II. Nonoperative management, tricuspid valve annuloplasty, and tricuspid valve replacement. | journal=J Thorac Cardiovasc Surg | year= 1987 | volume= 94 | issue= 4 | pages= 488-97 | pmid=3657251 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3657251  }} </ref> Severe TR with [[pulmonary hypertension]]/[[right heart failure|right ventricular dysfunction]] has a worse prognosis and frequently requires surgical intervention. Isolated [[mitral valve surgery]] for mitral valve abnormalities is associated with no improvement of TR in the majority of patients.<ref name="pmid7934109">{{cite journal| author=Sagie A, Schwammenthal E, Palacios IF, King ME, Leavitt M, Freitas N et al.| title=Significant tricuspid regurgitation does not resolve after percutaneous balloon mitral valvotomy. | journal=J Thorac Cardiovasc Surg | year= 1994 | volume= 108 | issue= 4 | pages= 727-35 | pmid=7934109 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7934109  }} </ref> It is also not uncommon to have residual TR following isolated left-sided valve surgery, especially when some preoperative risk factors are present.<ref name="pmid25402599">{{cite journal| author=Zhu TY, Min XP, Zhang HB, Meng X| title=Preoperative risk factors for residual tricuspid regurgitation after isolated left-sided valve surgery: a systematic review and meta-analysis. | journal=Cardiology | year= 2014 | volume= 129 | issue= 4 | pages= 242-9 | pmid=25402599 | doi=10.1159/000367589 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25402599  }} </ref> Tricuspid valve surgery at the time of left-sided valvulopathy decreases the rate of post-operative residual tricuspid regurgitation.<ref name="pmid9576162">{{cite journal| author=Tager R, Skudicky D, Mueller U, Essop R, Hammond G, Sareli P| title=Long-term follow-up of rheumatic patients undergoing left-sided valve replacement with tricuspid annuloplasty--validity of preoperative echocardiographic criteria in the decision to perform tricuspid annuloplasty. | journal=Am J Cardiol | year= 1998 | volume= 81 | issue= 8 | pages= 1013-6 | pmid=9576162 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9576162  }} </ref>


Revision as of 23:10, 13 April 2020

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Rim Halaby, M.D. [2], Fatimo Biobaku M.B.B.S [3]

Overview

Tricuspid regurgitation (TR) is a common finding. TR is mostly a trace or mild regurgitation and usually has no symptoms when pulmonary hypertension and heart failure are absent.[1] However, moderate and severe TR are associated with increased morbidity and mortality. The more severe the TR, the worse the prognosis.[1]

Natural History, Complications, and Prognosis

Natural History

TR is a common valvular abnormality usually presenting with no symptoms when pulmonary hypertension and heart failure are absent.[1] When symptoms are present, they develop progressively. TR might not be recognised clinically until fairly late in its natural history.[2] Patients with significant TR may remain asymptomatic, despite impaired right ventricular function.[3] Significant degrees of TR have been noted with the onset of atrial fibrillation, especially in older patients above 75 years of age.[2] TR can be present in isolation or associated with other medical conditions. TR commonly occurs among patients with mild/moderate mitral regurgitation (MR) or mitral stenosis. Approximately 30-50% of patients with severe MR have significant secondary TR.[3][4][5] Severe TR with pulmonary hypertension/right ventricular dysfunction has a worse prognosis and frequently requires surgical intervention. Isolated mitral valve surgery for mitral valve abnormalities is associated with no improvement of TR in the majority of patients.[6] It is also not uncommon to have residual TR following isolated left-sided valve surgery, especially when some preoperative risk factors are present.[7] Tricuspid valve surgery at the time of left-sided valvulopathy decreases the rate of post-operative residual tricuspid regurgitation.[8]

Risk factors for residual TR following isolated left-sided valve surgery

There is an increased risk of residual tricuspid regurgitation following isolated left-sided valve surgery if the following preoperative risk factors are present:[7]

Complications

Complications of tricuspid regurgitation include:[9][10][11]

Prognosis

Increased morbidity and mortality is associated with moderate and severe TR. The higher the severity of the TR, the worse the prognosis.[1][12][13] 5223 ambulatory patients in the US Veteran’s Health Administration system were followed up for 4 years, and increasing severity of tricuspid regurgitation was associated with worse survival ( independent of age, biventricular systolic function, right ventricular size, and inferior vena cava dilatation).[14][15] Severe isolated TR is associated with a worse prognosis compared to the general population.[16] The 5-year survival was 74% in 813 patients with moderate or severe, isolated tricuspid regurgitation who were medically managed and followed up at a center in South Korea.[2][17] Tricuspid regurgitation has been independently associated with reduced long-term survival in patients with ischemic or idiopathic left ventricular systolic dysfunction, with or without clinical heart failure.[2][18][19] Right ventricular dysfunction is associated with postoperative morbidity and mortality following tricuspid valve surgery.[20] Residual TR following TV repair during concomitant left-sided valve surgery is associated with increased morbidity and mortality.[21]

References

  1. ↑ 1.0 1.1 1.2 1.3 Nath J, Foster E, Heidenreich PA (2004). "Impact of tricuspid regurgitation on long-term survival". J Am Coll Cardiol. 43 (3): 405–9. doi:10.1016/j.jacc.2003.09.036. PMID 15013122.
  2. ↑ 2.0 2.1 2.2 2.3 Rodés-Cabau J, Taramasso M, O'Gara PT (2016). "Diagnosis and treatment of tricuspid valve disease: current and future perspectives". Lancet. 388 (10058): 2431–2442. doi:10.1016/S0140-6736(16)00740-6. PMID 27048553 PMID: 27048553 Check |pmid= value (help).
  3. ↑ 3.0 3.1 Dreyfus GD, Martin RP, Chan KM, Dulguerov F, Alexandrescu C (2015). "Functional tricuspid regurgitation: a need to revise our understanding". J Am Coll Cardiol. 65 (21): 2331–6. doi:10.1016/j.jacc.2015.04.011. PMID pmidPMID:_26022823 Check |pmid= value (help).
  4. ↑ Koelling TM, Aaronson KD, Cody RJ, Bach DS, Armstrong WF (2002). "Prognostic significance of mitral regurgitation and tricuspid regurgitation in patients with left ventricular systolic dysfunction". Am Heart J. 144 (3): 524–9. PMID 12228791 PMID: 12228791 Check |pmid= value (help).
  5. ↑ Cohen SR, Sell JE, McIntosh CL, Clark RE (1987). "Tricuspid regurgitation in patients with acquired, chronic, pure mitral regurgitation. II. Nonoperative management, tricuspid valve annuloplasty, and tricuspid valve replacement". J Thorac Cardiovasc Surg. 94 (4): 488–97. PMID 3657251.
  6. ↑ Sagie A, Schwammenthal E, Palacios IF, King ME, Leavitt M, Freitas N; et al. (1994). "Significant tricuspid regurgitation does not resolve after percutaneous balloon mitral valvotomy". J Thorac Cardiovasc Surg. 108 (4): 727–35. PMID 7934109.
  7. ↑ 7.0 7.1 Zhu TY, Min XP, Zhang HB, Meng X (2014). "Preoperative risk factors for residual tricuspid regurgitation after isolated left-sided valve surgery: a systematic review and meta-analysis". Cardiology. 129 (4): 242–9. doi:10.1159/000367589. PMID 25402599.
  8. ↑ Tager R, Skudicky D, Mueller U, Essop R, Hammond G, Sareli P (1998). "Long-term follow-up of rheumatic patients undergoing left-sided valve replacement with tricuspid annuloplasty--validity of preoperative echocardiographic criteria in the decision to perform tricuspid annuloplasty". Am J Cardiol. 81 (8): 1013–6. PMID 9576162.
  9. ↑ Anyanwu AC, Adams DH (2010). "Functional tricuspid regurgitation in mitral valve disease: epidemiology and prognostic implications". Semin Thorac Cardiovasc Surg. 22 (1): 69–75. doi:10.1053/j.semtcvs.2010.05.006. PMID 20813320.
  10. ↑ Naschitz JE, Goldstein L, Zuckerman E, Yeshurun D, Wolfson V (2000). "Benign course of congestive cirrhosis associated with tricuspid regurgitation: does pulsatility protect against complications of venous hypertension?". J Clin Gastroenterol. 30 (2): 213–4. PMID 10730933.
  11. ↑ Bruce CJ, Connolly HM (2009). "Right-sided valve disease deserves a little more respect". Circulation. 119 (20): 2726–34. doi:10.1161/CIRCULATIONAHA.108.776021. PMID pmid19470901 Check |pmid= value (help).
  12. ↑ Taramasso M, Vanermen H, Maisano F, Guidotti A, La Canna G, Alfieri O (2012). "The growing clinical importance of secondary tricuspid regurgitation". J Am Coll Cardiol. 59 (8): 703–10. doi:10.1016/j.jacc.2011.09.069. PMID 22340261.
  13. ↑ Cohen SR, Sell JE, McIntosh CL, Clark RE (1987). "Tricuspid regurgitation in patients with acquired, chronic, pure mitral regurgitation. I. Prevalence, diagnosis, and comparison of preoperative clinical and hemodynamic features in patients with and without tricuspid regurgitation". J Thorac Cardiovasc Surg. 94 (4): 481–7. PMID 3657250.
  14. ↑ Rodés-Cabau J, Taramasso M, O'Gara PT (2016). "Diagnosis and treatment of tricuspid valve disease: current and future perspectives". Lancet. 388 (10058): 2431–2442. doi:10.1016/S0140-6736(16)00740-6. PMID pmidPMID:_27048553 Check |pmid= value (help).
  15. ↑ Nath J, Foster E, Heidenreich PA (2004). "Impact of tricuspid regurgitation on long-term survival". J Am Coll Cardiol. 43 (3): 405–9. doi:10.1016/j.jacc.2003.09.036. PMID 15013122 PMID: 15013122 Check |pmid= value (help).
  16. ↑ Topilsky Y, Nkomo VT, Vatury O, Michelena HI, Letourneau T, Suri RM; et al. (2014). "Clinical outcome of isolated tricuspid regurgitation". JACC Cardiovasc Imaging. 7 (12): 1185–94. doi:10.1016/j.jcmg.2014.07.018. PMID 25440592.
  17. ↑ Lee JW, Song JM, Park JP, Lee JW, Kang DH, Song JK (2010). "Long-term prognosis of isolated significant tricuspid regurgitation". Circ J. 74 (2): 375–80. PMID 20009355 PMID: 20009355 Check |pmid= value (help).
  18. ↑ Hung J, Koelling T, Semigran MJ, Dec GW, Levine RA, Di Salvo TG (1998). "Usefulness of echocardiographic determined tricuspid regurgitation in predicting event-free survival in severe heart failure secondary to idiopathic-dilated cardiomyopathy or to ischemic cardiomyopathy". Am J Cardiol. 82 (10): 1301–3, A10. PMID 9832116 PMID: 9832116 Check |pmid= value (help).
  19. ↑ Neuhold S, Huelsmann M, Pernicka E, Graf A, Bonderman D, Adlbrecht C; et al. (2013). "Impact of tricuspid regurgitation on survival in patients with chronic heart failure: unexpected findings of a long-term observational study". Eur Heart J. 34 (11): 844–52. doi:10.1093/eurheartj/ehs465. PMID 23335604 PMID: 23335604 Check |pmid= value (help).
  20. ↑ Pozzoli A, Elisabetta L, Vicentini L, Alfieri O, De Bonis M (2016). "Surgical indication for functional tricuspid regurgitation at initial operation: judging from long term outcomes". Gen Thorac Cardiovasc Surg. 64 (9): 509–16. doi:10.1007/s11748-016-0677-5. PMID 27329290.
  21. ↑ Sorabella RA, Mamuyac E, Yerebakan H, Najjar M, Choi V, Takayama H; et al. (2015). "Residual Tricuspid Regurgitation following Tricuspid Valve Repair during Concomitant Valve Surgery Worsens Late Survival". Heart Surg Forum. 18 (6): E226–31. doi:10.1532/hsf.1469. PMID 26726709.

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