With improving surgical care yielding better outcomes, patients who have undergone a cardiac operation are surviving longer, and surgeons will inevitably face an increasing number of reoperative procedures [1].

Tricuspid regurgitation may occur as an early or late complication after surgical procedures for congenital heart disease.

Tricuspid regurgitation may occur early as a result of tricuspid valve distortion as a consequence of septal defect surgical repair or late as a sequela of the progression of right ventricular failure.

Tricuspid valve dysfunction as a secondary consequence of right ventricular dilatation and failure (functional tricuspid valve regurgitation) will be extensively treated in Chap. 12.

Surgical injury of the tricuspid valve is a quite uncommon complication that has been mainly associated with ventricular septal defect (VSD) closure, partial or complete atrioventricular septal defect (AVSD) repair, and tetralogy of Fallot (TF) repair.

The majority of the VSDs are closed through the right atrium. This technique requires retracting tricuspid valve leaflets for better VSD exposure with possible tricuspid apparatus injury and tricuspid valve regurgitation. Although really few patients develop severe regurgitation immediately after transatrial repair, mild to moderate degree of tricuspid regurgitation are very often present.

To address problems posed by VSD transatrial closure, surgeons have used temporary detachment of tricuspid leaflets as a different technique.

Chordal attachment, the VSD position, and the ventriculoinfundibular fold may reduce visibility of the VSD edges. Temporarily detaching of the tricuspid leaflets may improve VSD exposure with accurate suture placement avoiding residual shunt and tricuspid distortion.

Surprisingly, clinical studies did not find any onset of postoperative tricuspid regurgitation associated with radial [2, 3] or circumferential [4] incision of tricuspid leaflets during VSD closure. In fact patients who underwent temporary detachment of tricuspid leaflets exhibit lower rates of regurgitation than patients who underwent traditional approach [4, 5].

Another [6] technique described for better exposure of the VSD is the temporarily detachment of the chordae of the obscuring tricuspid valve from the attachment to the septum. The chorda tendinea is, after the procedure, reattached with a pledgeted suture to the septum. We believe that this technique can have high risk of the dehiscence of the reattachment with consequent immediate severe valve insufficiency.

Other possible mechanism of tricuspid valve regurgitation after VSD closure is the VSD patch anchoring. Papillary muscle and chordae to the tricuspid valve are often attached around the VSD and therefore potentially damaged by VSD closure. This is particularly the case posteriorly, where the VSD patch is anchored away from the margin of a perimembranous defect to avoid conduction system. To avoid iatrogenic postoperative atrioventricular block, part of the septal tricuspid leaflet is often used for anchoring the VSD patch. This technique preserves the conduction system but can cause valve fixation and distortion [7].

Independently of the mechanism, we can say that significant tricuspid valve regurgitation is a rare complication after VSD closure. Tricuspid valve detachment is a safe method to enhance the exposure of the VSD resulting in less early postoperative tricuspid valve regurgitation and does not result in tricuspid valve dysfunction during follow-up [5].

An increasing number of adults with repaired TF have late complications, such as arrhythmias, right ventricular failure, and sudden death. These complications result from tricuspid and pulmonary regurgitation, right ventricular dilation and dysfunction, residual VSD, and stenosis of the right ventricular outflow tract (RVOT) and pulmonary arteries. Reoperation for chronic pulmonary valve regurgitation following initial TF repair is today the most frequently performed in adults with congenital heart disease and is generally performed with good results [8]. Results in reoperation for severe tricuspid valve regurgitation are less encouraging [7] and although tricuspid regurgitation is a minor complication after the initial TF repair, it becomes serious when chronic right ventricular dysfunction occur complicated by liver dysfunction.

The incidence of moderate to severe tricuspid regurgitation after TF repair is reported in the literature between 11 and 19 % [7, 9].

All the mechanisms already explained for postoperative tricuspid regurgitation after VSD closure can be applied after TF repair placing the tricuspid valve at risk for direct damage.

In addition to closing the VSD, RVOT obstruction relief is another objective of TF repair that can unintentionally impair the tricuspid valve function.

Right ventricular aggressive infundibulum resection to relieve RVOT obstruction carries the potential to damage the tricuspid tensor apparatus. The caudal limb of the septomarginal trabeculation usually gives rise, in the RV, to the medial papillary muscle of the tricuspid valve. These hypertrophied bands are usually resected during this procedure. Direct injury to the chordae tendineae or resection of the RVOT has been associated with tricuspid flail leaflets [10].

Finally in these patient, progressive right ventricular dysfunction and dilatation as consequence of long-standing chronic pulmonary valve insufficiency can amplify the degree of severity of the tricuspid regurgitation in the follow-up.

Summarizing, the most common causes of tricuspid regurgitation after TF repair are intraoperative injury to the tricuspid valve or its attachment, distortion of the valve as a result of anchoring the VSD patch to the septal leaflet, and progressive dilatation due to chronic volume overload of the RV.

While left atrioventricular valve regurgitation represents the most common indication for reoperation after partial and complete AVSD repair, right atrioventricular valve regurgitation seems to occur less frequently.

The Mayo Clinic group published [11, 12] the reoperations performed after initial repair of partial and complete AVSD over a long period (45 and 35 years, respectively).

Tricuspid regurgitation is a rare complication in the follow-up of these patients and surprisingly is much more frequent after partial AVSD repair than complete AVSD repair.

Twenty percentage of the patients submitted for reoperation after partial AVSD repair received a tricuspid valve surgery as associated surgical procedures. Isolated tricuspid valve repair or replacement was present in only 2 % of the cases presented [11].

Independently of the patient’s type, treatment of the tricuspid regurgitation depends on its causes and clinical status.

Echocardiography provides a valuable assessment of tricuspid regurgitation. Tricuspid regurgitation grading is usually assessed as four grades using color-Doppler flow imaging to characterize flow direction in the inferior vena cava or hepatic veins, as grade 0 = absent, 1 = trace, 2 = mild, 3 = moderate, and 4 = severe.

Surgical injury during septal defect repair may require tricuspid repair or replacement depending of the grade of the regurgitation.

Recent guidelines from the American College of Cardiology (ACC) and American Heart Association (AHA) [13] say that mild, asymptomatic regurgitation is not an indication for surgical intervention.

Medical treatment is currently used to treat moderate regurgitation. Severe tricuspid regurgitation is today the only clinical condition recommended for surgical repair.

In the presence of damaged leaflets, clinical symptoms, pulmonary hypertension, or annular dilatation, tricuspid valve surgery should be considered in case of severe regurgitation.

Clearly, although tricuspid valve repair is preferable to tricuspid valve replacement, it remains unclear which techniques are optimal for repairing the tricuspid valve.

Different annuloplasty techniques and the prosthetic rings are the most commonly used and reported procedures for tricuspid valve repair. Other techniques include suture bicuspidization, edge-to-edge clover technique, and leaflet patch augmentation.