What are the treatment options for a patient with a tricuspid aortic valve?

Tricuspid Aortic Valve

Important Clarification

A tricuspid aortic valve is the normal anatomic configuration of the aortic valve, consisting of three cusps (right, left, and non-coronary), and typically requires no treatment unless pathology develops. 1

The question appears to be asking about treatment options for a normal tricuspid aortic valve, which is distinct from a bicuspid aortic valve (an abnormal two-cusp configuration). If you are asking about tricuspid valve disease (the valve between the right atrium and right ventricle), please clarify, as the management is entirely different.

When a Tricuspid Aortic Valve Requires Treatment

Aortic Regurgitation in Tricuspid Aortic Valves

For patients with a tricuspid aortic valve who develop aortic regurgitation, surgical repair is now feasible in more than half of cases when systematic intraoperative assessment is performed, with valve replacement reserved for cases with cusp retraction, perforation, or extensive calcification. 2

Mechanisms of Regurgitation and Treatment Selection

• Cusp prolapse (most commonly involving the right cusp in 86% of cases) is the most frequent single mechanism causing aortic regurgitation in tricuspid aortic valves and is strongly associated with successful valve repair 2
• Cusp retraction (24% of cases) and perforation (18% of cases) are more commonly treated with valve replacement rather than repair 2
• Younger age, larger patient size, and isolated prolapse predict successful repair, while older age, retraction, perforation, and concomitant mitral repair predict need for replacement 2

Surgical Approach for Aortic Regurgitation

• Valve repair should be attempted when cusp prolapse is the primary mechanism, particularly in younger patients without extensive calcification or cusp retraction 2
• Valve replacement with a bioprosthesis is preferred when valve leaflets are diseased, abnormal, or destroyed, as biological prostheses have lower thromboembolic complications than mechanical valves 1
• Tricuspidization techniques (creating a tricuspid valve from a bicuspid valve) can restore normal function, but this applies to bicuspid valves being converted to tricuspid configuration, not treatment of native tricuspid valves 3

Aortic Stenosis in Tricuspid Aortic Valves

• When tricuspid aortic valves develop stenosis (typically from calcification or rheumatic disease), valve replacement is the standard treatment 1
• Mixed aortic valve disease combining stenosis and regurgitation is most commonly treated with valve replacement 1

Associated Aortic Root Disease

• When aortic regurgitation occurs with aortic root dilatation, valve-sparing aortic root replacement is increasingly employed in expert centers, especially in young patients 1
• Patients with bicuspid aortic valves have higher aortic diameter growth rates, but those with tricuspid aortic valves of similar aortic size may have comparable risk profiles 1

Diagnostic Evaluation

• Echocardiography is essential for assessing valve structure, motion, annular size, and severity of regurgitation or stenosis 1
• 2D transesophageal echocardiography has limited accuracy for mechanistic assessment, with 73-82% accuracy for right cusp pathology, 55-61% for non-coronary cusp, and 0% for left coronary cusp 2
• Intraoperative transesophageal echocardiography allows refinement of repair techniques and immediate assessment of surgical results 1

Critical Pitfalls to Avoid

• Do not confuse tricuspid aortic valve (normal three-cusp aortic valve) with tricuspid valve disease (pathology of the valve between right atrium and ventricle) 4, 5
• Do not assume all aortic regurgitation in tricuspid aortic valves requires replacement—systematic intraoperative assessment can identify repair candidates in >50% of cases 2
• Do not delay surgery in symptomatic patients with severe aortic regurgitation and preserved left ventricular function, as outcomes worsen with progressive ventricular dysfunction 1