Tricuspid annular dimension is commonly assessed via transthoracic or transesophageal echocardiogram. It is important to appreciate that TV regurgitation is dynamic and may have some variability between echocardiographic assessments. Therefore, the operator should make a summative evaluation of regurgitation severity based on both preoperative and intraoperative studies. Detection and quantitation of TR is performed through a combination of two-dimensional echocardiography, color flow Doppler, and spectral Doppler. The tricuspid valve can be evaluated intraoperatively by transesophageal echocardiography (TEE) in several views at the mid-esophageal (ME) level: four-chamber view, right ventricular inflow-outflow view, and modified bicaval. When performing the TEE, a four-chamber mid-esophageal view is obtained, and the probe is turned to the right to optimize visualization of the TV and annulus [8]. Color flow Doppler can facilitate assessment of TR by measuring the width of the vena contracta of the regurgitant jet as well as area of the regurgitant jet in the right atrium. A vena contracta width greater than 0.7 cm and a jet area greater than 10 cm² are criteria for the grade of severe TR. However, despite its simplicity, color flow Doppler is limited by technical and hemodynamic factors such as color gain, frame rate, and decrease in preload and afterload that occur under general anesthesia. Spectral Doppler can provide additional clues regarding the severity of tricuspid regurgitation. A dense, triangular-shaped, early peaking Doppler envelope of the regurgitant jet by continuous wave Doppler is consistent with severe TR. Hepatic vein flow systolic reversal by pulsed-wave Doppler of the hepatic veins is specific but relatively insensitive for the presence of severe TR. Tricuspid annulus diameter can be measured by TEE in the ME four-chamber view or the ME right ventricular inflow-outflow view or by transthoracic in the apical four-chamber or the parasternal short axis view. Given the complex anatomy of the TV and the tricuspid annulus, the geometric assumptions of the regurgitant orifice, and the limitations of each technique, no parameter should be used in isolation, but rather a comprehensive evaluation should be performed. Semiquantitative characterization of TR is determined by measuring the distance of the regurgitate jet from the tricuspid orifice toward the posterior wall. The severity scale is none (grade 0), mild (grade I), moderate (grade II), and severe (grade III/IV) [13].

Appropriate vascular access and monitoring (e.g., pulmonary artery catheter) are obtained in the intubated patient in the operating room after induction of general anesthesia. A careful intraoperative transesophageal echocardiographic assessment for valvular abnormalities, atrial septal defect, and right ventricular function is obtained. TV intervention is planned if moderate or severe TR is confirmed. TV repair during LVAD implantation necessitates a median sternotomy approach with bicaval venous cannulation. Umbilical tapes may be placed around the SVC and IVC. However, vacuum-assisted venous drainage may obviate the need for caval snares. Following full cardiopulmonary bypass, the right atrium is opened. Notably, cardioplegic arrest and aortic cross clamping is not required in most cases. Care is taken to avoid injury to permanent pacer leads, which may be present in the right atrium. The pulmonary artery catheter tip is extracted from the right atrium and moved out of the immediate surgical field. The tricuspid valve is exposed, and assessment of annulus size, leaflet pathology, and position of any leads is performed. TV competence is tested by injecting saline into the RV. It is important to confirm that the RV shocking lead does not tether or perforate any of the leaflets. If the lead perforates any leaflet, this must be rectified in addition to the annuloplasty.

After confirming significant TR, if the findings suggest a dilated annulus without significant leaflet disease, an annuloplasty using a semi-rigid partial ring is most commonly performed [11]. This usually consists of 7–9 annular stitches using a 2-0 braided suture that spares the conduction system in the septal area. A 26 or 28 mm semi-rigid annuloplasty ring generally achieves significant downsizing of the annulus. Others have had success using suture annuloplasty techniques. The De Vega suture annuloplasty is performed using 3-0 polypropylene suture in mattress technique supported by pericardial or felt pledgets [12]. The Kay (bicuspidization) annuloplasty is performed by plication of the posterior leaflet annulus using pledgeted 4-0 polypropylene horizontal mattress sutures [10, 14].

Primary leaflet pathology or damage (e.g., perforation, tethering, subvalvular chordal fusion), often from pacer/defibrillator leads traversing the tricuspid valve (TV), may preclude an adequate repair with annuloplasty alone. If there is leaflet pathology not amenable to a simple repair strategy such as the closure of a cleft or patching a perforation, TV replacement with a bioprosthesis is recommended. We do not recommend a mechanical prosthesis for the TV position due to the elevated risks of thrombosis, while a bioprosthesis tends to have a durable course with an 89% freedom from reoperation at 10 years [15–19].

Following completion of the tricuspid intervention, the pulmonary artery catheter is maneuvered back into the pulmonary artery manually, and the right atrium is closed in two layers using 4-0 Prolene suture. We then proceed with the LVAD implant portion of the operation. Lifting of the left ventricular apex anteriorly for exposure to place the LVAD inflow cannula has not caused disruption of the tricuspid repair or replacement in our experience. After weaning off cardiopulmonary bypass, the TV is again assessed on TEE, and we would accept mild or less TR as a reasonable result.