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Purpose: patients with functional tricuspid regurgitation (FTR) at the time of mitral valve (MV) surgery are challenging. TR measured at 2D echocardiography (2DE) depends on right ventricular loading and contractility. 2DE is unreliable in the assessment of the tricuspid valve (TV) apparatus remodeling,and patients without significant TR can develop significant TR after MV surgery. The aim of our study is to demonstrate, by real-time 3D echocardiography (RT3DE), if patients with severe MV regurgitation (MR) have structural and functional remodeling of TV apparatus independently of degree of TR measured by transthoracic 2DE (2DTT).Methods: 55 patients with severe MR (60% degenerative, 27.3% functional and 12.7% rheumatic) and 13 matched controls were studied by 2D TTECHO and RT3D. 2D TT measurements included Tricuspid Annulus (TA) diameters. RT3DE measurements included TA area (TAA), TA fractional area change (TAFAC) from end-systolic and end-diastolic areas, the TA major and minor diameters were also measured. FTR was quantified by vena contracta (VC).Results: there are significant differences in TA morphology and function among patients and controls: 2D TT systolic diameter (2.7+0.4vs 2.3+0.3 cm, p= 0.0005),2D TT fractional shortening (17.8+7.1% vs 27.7+5.8%, p=0.0001), RT3D TA minor (2.1+0.56 vs 1.6+0.5cm, p=0.005) and major (2.9+0.58 vs 2.3+0.48 cm, p=0.001) diameters, TAAsystolic (6.4+2,1 vs 3,6+0.7 cm2, p=0.0001) and diastolic (8.2+2.1vs 6.0+1.3 cm2, p=0.0006) and TAFAC (22.2+10.6% vs 36.9+10.5%, p=0.0003), whereas no difference was found in 2D TT diastolic diameter (3.3+0.5vs 3.2+0.3, p= 0.1). 2D TT measures compared with RT3D measures underestimate TA diameter. At multivariate linear regression analysis, the strongest predictors of VC are RT3D systolic (p=0.0002) and diastolic area (p=0.0016) and TAFAC (p=0.002); 2D TT systolic diameter (p=0.004), 2D TT diastolic and fractional shortening are also predictors (p= 0.008). When patients are divided into 2 groups based on the severity of FTR, we observed a significant enlarged annulus and impaired function of TV in patients with trivial-mild FTRcompared to matched controls: TA systolic diameter (p= 0.02), fractionalshortening (p=0.0005), 3D systolic area (p=0.0001), 3D diastolic area(p=0.003), 3D diameter minor (p=0.003) and major (p=0.01) and TAFAC (p=0.0002).Conclusions: In patients with FTRRT3D anatomical and functional parameters of TV apparatus are the strongest predictors of TR VC. RT3D evaluation also demonstrates a significant remodeling and functional impairment of TV apparatus in patients with severe MR and trivial-mild FTR.