From the Guidelines
Syncope in tricuspid regurgitation is a serious condition that requires prompt management, and surgical intervention with valve repair or replacement may be necessary for severe cases, as recommended by the 2022 AHA/ACC/HFSA guideline 1.
Management of Syncope in Tricuspid Regurgitation
The management of syncope in tricuspid regurgitation focuses on treating the underlying cause of tricuspid regurgitation while providing supportive care for syncope episodes.
- For acute management of syncope, place the patient in a supine position with elevated legs to improve venous return.
- Medical therapy typically includes diuretics like furosemide 20-40mg daily to reduce volume overload, and ACE inhibitors such as enalapril 2.5-10mg twice daily to decrease afterload.
- Beta-blockers like metoprolol 25-100mg twice daily may help control heart rate in patients with atrial fibrillation.
Severity of Tricuspid Regurgitation
The severity of tricuspid regurgitation can be assessed using the stages of TR, as outlined in the 2014 AHA/ACC guideline 1.
- Stage D is characterized by symptomatic severe TR, with a central jet area >10.0 cm2, and is associated with fatigue, palpitations, dyspnea, abdominal bloating, anorexia, and edema.
- The management of stage D TR involves surgical intervention, as recommended by the 2014 AHA/ACC guideline 1.
Monitoring and Follow-up
Regular follow-up with echocardiography is essential to monitor disease progression and treatment response, as recommended by the 2014 AHA/ACC guideline 1.
- Patients should be advised to change positions slowly, stay well-hydrated, and avoid triggers like prolonged standing.
- Syncope occurs in tricuspid regurgitation because severe regurgitation reduces forward cardiac output, especially during exertion or when venous return is compromised, leading to cerebral hypoperfusion.
From the Research
Tricuspid Regurgitation and Syncope
- Tricuspid regurgitation (TR) is a valvular disease that can lead to significant morbidity and mortality, with a prevalence of 1.6 million individuals in the United States and 3.0 million people in Europe 2.
- The disease can cause symptoms such as syncope, which can be a result of the reduced cardiac output and increased right ventricular pressure 3.
- Functional TR, the most common form of TR, is caused by cardiomyopathies, LV valve disease, or pulmonary disease, and can lead to right ventricular dilatation and failure 2.
Pathophysiology and Diagnosis
- The tricuspid valve has a broad anatomical variability, and TR can be classified as primary or secondary/functional, with functional TR being the most prevalent 3.
- The diagnosis of TR can be made using multi-modality imaging, including echocardiography, which can assess the TR etiology/severity, measure RA and RV size and function, estimate pulmonary pressure, and characterize LV disease 2, 4.
- The severity of TR can be graded using a multi-parametric echocardiographic approach, which can help determine the appropriate management solutions 5.
Management and Treatment
- The management of TR includes diuretics, ACE inhibitors, and aldosterone antagonists, as well as surgical annuloplasty or valve replacement in patients with progressive RV dilatation without severe LV dysfunction and pulmonary hypertension 2.
- Transcatheter repair/replacement is a emerging therapy for high-risk patients with TR, which can provide an effective treatment option for patients not eligible for surgery 2, 3, 6.
- Early diagnosis and referral for treatment are essential to impact the natural history of TR, and a better understanding of the different stages of disease and potential treatment options is needed 4.