Quality and duration of long-term survival are related to residual RV function. In patients with severe symptomatic primary TR from either device leads or endomyocardial biopsy, TR develops rap- idly, and surgery can be done before the onset of Correction of symptomatic severe primary TR (Stage D) in patients without left-sided valve disease would preferentially be per- formed before the onset of significant RV dysfunc- tion or end-organ damage. Randomized studies of early intervention are lacking, and the benefit might be limited by the risk of intervention, subop- timal reduction in TR severity, or suboptimal dura- bility of currently available approaches to tricuspid valve repair and replacement. 4. There is now recognition that TR can develop in association with AF and annular dilation (a form of Notably, AF-related TR appears to represent a fundamentally different pathophysiol- ogy from other forms of secondary TR, with greater basal dilation and annular enlargement, as com- pared with the RV elongation with leaflet tethering seen in patients who have secondary TR caused by pulmonary hypertension or myocardial disease.24 These patients with AF-related TR have rapid pro- gression of TR severity and right-sided chamber dila- tion. In appropriately selected symptomatic patients with AF-related severe TR, quality of life and symp- toms can be improved by surgical intervention for TR. In patients undergoing intervention, overall outcomes are better in those without severe RV dysfunction or end-organ damage. Newer surgical techniques and a better selection process resulted in an acceptable operative mortality rate (<4% to 5%) for isolated TR in selected patients.2,11,12,15 19,22,38 5. The optimal timing of tricuspid valve surgery for asymptomatic or minimally symptomatic patients with severe primary TR has not been established. 