There are four valves in our heart. One of these valves, the tricuspid valve, is located on the right side of the heart, between the right atrium and the right ventricle. It has a structure and function similar to the mitral valve on the left side of the heart. Like the mitral valve, it is a one-way valve that must open and close properly, allowing blood to flow from the atrium to the ventricle. The tricuspid valve ensures that all the deoxygenated blood returning to the heart from the body flows completely into the right ventricle. From there, the blood is pumped into the pulmonary artery and sent to the lungs to be oxygenated. In short, similar to the mitral valve, it functions like a door that opens forward and closes back at the same point. To perform its function correctly, it must open during the relaxation phase of the heart (diastole) and close completely during heart contraction (systole).
The tricuspid valve is structurally composed of three leaflets that are positioned opposite each other and touch one another without leaving any gaps. These leaflets are firmly anchored to a region called the annulus, located between the atria and ventricles, and open and close one-way toward the ventricle. The opening and closing function is supported by fibrous cords called chordae tendineae, which are attached to the tips and bodies of the leaflets and move in sync with the contraction of the heart.
When the tricuspid valve is open, all blood coming into the right atrium should flow into the right ventricle. During systole, the phase of heart contraction, the tricuspid valve closes completely, allowing all the blood in the ventricle to be pumped through the pulmonary valve to the lungs. During this pumping phase, the valve must be fully closed to ensure that all blood in the ventricle is pumped into the lungs. If the valve does not open or close properly, some blood may remain in the right atrium, increasing pressure in the venous system.
Rheumatic heart disease is one of the most common causes of tricuspid valve stenosis. Over time, the valve tissue thickens, losing its flexibility and preventing the valve from opening fully. The three leaflets may partially fuse together. As a result, during diastole, not all blood returning from the body to the heart can pass into the right ventricle, and some remains in the right atrium. The blood retained in the right atrium gradually causes thickening of the atrial walls and an increase in atrial pressure.
This rise in pressure reflects backward, leading to an increase in systemic venous pressure. Clinically, patients may develop prominent neck veins, leg edema, and abdominal swelling due to fluid accumulation in the abdomen (ascites). Initially, the heart rhythm may be regular, but over time it can become irregular, resulting in atrial fibrillation (AF). Treatment for tricuspid valve stenosis is generally surgical. If possible, the valve is repaired; if not, it is replaced. If the patient has AF, the rhythm disorder can also be addressed during surgery.
This is the most commonly observed tricuspid valve disease. It usually develops secondarily to a problem in the mitral valve (stenosis or regurgitation). In mitral valve disease, the increased pulmonary artery pressure causes a backward load on the right ventricle. As a result, the right heart enlarges, and the annulus of the tricuspid valve dilates. The widening of the tricuspid annulus pulls apart the leaflets that normally meet tightly, creating a gap. With each heartbeat, blood flows backward through this gap into the right atrium.
Another clinical cause of tricuspid regurgitation is infective endocarditis, where an infection settles on the tricuspid valve and deforms it. This is often seen in intravenous drug users and is a life-threatening condition that requires immediate treatment.
There is also a group of patients with pacemakers, where the leads (electrodes) pass through the tricuspid valve to the right ventricle. Over time, these leads can wear down the valve and cause tricuspid regurgitation. Sometimes, infections can occur on these leads, leading to infective endocarditis. In both scenarios, the only treatment is surgical intervention on the tricuspid valve.
Another group includes patients who previously underwent mitral valve surgery but had mild tricuspid regurgitation at the time, which was not addressed. Over time, tricuspid regurgitation can worsen. These patients may develop bilateral leg swelling, prominent neck veins, and abdominal swelling that cannot be controlled with diuretics. Shortness of breath often accompanies these symptoms. In such cases, the only effective treatment is surgical correction of the tricuspid valve regurgitation.
The most effective treatment for tricuspid regurgitation is to repair the valve and eliminate the underlying cause, which can only be achieved through proper and effective surgical intervention.
In this new surgical technique, the sternum is not cut. Instead, we access the heart from the right side of the chest through a small incision (3–4 cm) made at the level of the nipple or around the breast tissue in men, and just below the breast in women, passing between the ribs. An additional small incision (2–3 cm) is made in the right groin to reach the femoral artery and vein, through which cannulas are inserted to connect the patient to the heart-lung machine.
In most tricuspid valve repairs, we do not stop the heart, and the procedure is performed on the beating heart. By opening the patient’s right atrium, we reach the tricuspid valve and generally repair it. Every step of the procedure is performed under the guidance of a 3D endoscopic camera, with the surgical team viewing the heart on a large monitor using special glasses.
The camera provides high-definition images, and with the 3D glasses, the images appear three-dimensional just like with a robotic camera. This magnified 3D view allows the surgeon to see extremely fine details that would not be visible to the naked eye, while also providing a strong sense of depth, enabling highly safe and precise surgery. Today, many advanced centers in Europe and the United States perform surgeries using this method.
The small incision is not made to visualize the heart, but rather to provide a route for the valve or ring to enter the body. Therefore, the incisions are much smaller than those used in other minimal invasive heart surgeries, offering an excellent cosmetic outcome. Since the intercostal space is not widened with retractors, postoperative pain is significantly reduced.
Minimal incision heart surgery involves less manipulation of the heart, which in turn reduces trauma to the heart. In women, the incision is hidden under the breast, leaving no visible scar. Since the sternum is not cut, patients are not required to lie flat on their backs after surgery. Blood usage during and after surgery is also reduced. Patients can typically return to work within 2 weeks and resume activities such as driving. The risk of sternum infection, a major concern in traditional surgery, is eliminated. Overall, postoperative recovery time is reduced from 2–3 months in conventional surgery to 2–3 weeks with this method.
For patients undergoing a second or even third heart surgery, the procedure can be particularly risky. After previous surgeries, dense adhesions may form around the heart and aorta, which can pose a risk of injury or uncontrolled bleeding when dissected. In our surgeries, we reach the targeted area with a very small incision and 3D camera guidance, without disturbing these adhesions. This approach significantly reduces the risk of heart injury and bleeding, even in complex reoperations.
“There are four valves in our heart. One of these valves, the tricuspid valve, is located on the right side of the heart, between the right atrium and the right ventricle.”
The tricuspid valve is structurally composed of three leaflets that are positioned opposite each other and make complete contact without leaving any gaps.