Tricuspid and Mitral Valve Repair vs Replacement: A Surgeon's Real-World Approach

In Africans and Asians, coronary artery disease is largely driven by genetic predisposition. In Caucasians, the predominant driver is sedentary lifestyle combined with diet — high-fat foods, alcohol, physical inactivity — which more than compensates for their lesser genetic predisposition. Surgical outcomes are comparable worldwide, with success rates upward of 90% and combined morbidity and mortality after CABG around 5 to 7% regardless of country. But the numbers in Asia and Africa are hugely underrepresented — if one million cardiac deaths annually in sub-Saharan Africa is the current reported figure, the true number with adequate diagnostic infrastructure would likely be closer to three million.

The traditional Indian vegetarian population was genuinely following something close to this diet. What changed was cooking oil. Industrial cooking oils were repackaged and marketed under omega fatty acid branding — omega-3, then omega-6, now omega-9 — persuading consumers to abandon traditional cooking fats like mustard oil and olive oil for artificially processed, packaged products whose health claims aren't supported by meaningful clinical evidence. If the population simply returned to traditional cooking oils, it would likely cut the cardiac disease burden significantly. The pyramid isn't the problem; the oil in the pan is.

No, it does not. Gyms typically require only a basic medical certificate, not triglyceride, homocysteine or CRP levels. The supplement industry is enormous, largely unregulated and mostly not FDA-approved. And building muscle mass ignores that the heart is also a muscle — when it hypertrophies beyond physiological bounds, that's called hypertrophic cardiomyopathy, not fitness. The footballer Christian Eriksen is instructive: he had a cardiac event at Euro 2020, received an ICD, returned to professional football, and years later the ICD detected and treated an arrhythmic episode with a single defibrillation — he felt dizzy, walked off, and was alive. Shane Warne's death, by contrast, fit the classic pattern: lifelong smoking, crash diets, and heavy alcohol.

For patients above 55, LVADs have to a reasonable extent already replaced transplantation as destination therapy — they can run fifteen years without complications on antiplatelet and anticoagulant therapy alone, with no immunosuppression needed. Three developments will transform deceased-donor transplant over the next decade: donation after circulatory death, which could roughly double the donor pool; ex vivo machine perfusion devices like the TransMedics Organ Care System, which keep a donor heart beating outside the body for twelve to twenty-four hours or more, making cross-continental transport feasible; and xenotransplantation, with genetically modified pig hearts already transplanted into two human recipients. It's unlikely any engineered device will fully replicate a natural heart, though — transplantation will stay relevant for at least the next fifteen to twenty-five years.

The first step is an urgent echocardiogram to establish ejection fraction precisely using Simpson's biplane method — the clinical picture at 35% and at 20% are entirely different territories. Below 20%, options are very limited; diuretics alone won't fully resolve the oedema. The Aquadex SmartFlow ultrafiltration system, with a 15ml prime volume removing 60 to 100ml of fluid per hour, is the logical next step when diuretics are failing. But with ejection fraction below 20% in the context of HIV and TB, and hypotension further constraining options, the situation is close to endgame — peritoneal dialysis is theoretically possible, but introducing a device into the body cavity of a patient with active communicable disease carries an infection risk that makes it unsafe in most circumstances.

Because a mechanical valve in the low-pressure tricuspid position carries a high thrombosis risk that can escalate into a fatal pulmonary embolism, making a bioprosthetic valve the safer choice when replacement is unavoidable.

The traditional DeVega repair or an annuloplasty ring; transcatheter edge-to-edge repair (TriClip, MitraClip) is treated as a genuine last resort, used only once every surgical option has been exhausted.

That mitral valve replacement offers better freedom from re-operation at eight to ten years, compared with repair, which typically holds for only five to six years.

In a healthcare system where re-operation is accessible and affordable; where a fix needs to last a lifetime, replacement is the stronger strategy.