From the Guidelines
The tricuspid valve assessment shows normal structure with trivial regurgitation and no stenosis, indicating no need for specific intervention. The inferior vena cava (IVC) caliber is 1.3 cm with greater than 50% respiratory variation, indicating normal right atrial pressure, which is confirmed by the measured right atrial pressure of 3 mmHg 1. The tricuspid regurgitation velocity is 1.2 m/s, which is within normal limits. These findings collectively suggest normal right heart hemodynamics with no evidence of pulmonary hypertension or significant tricuspid valve disease. Some key points to consider in the management of tricuspid regurgitation include:
- Trivial regurgitation is a common physiological finding present in many healthy individuals and does not require treatment 1.
- The 2017 ESC/EACTS guidelines for the management of valvular heart disease provide indications for surgery in tricuspid regurgitation, including a tricuspid annulus > 40 mm or > 21 mm/m2, decline in RV function, and severe RV or LV dysfunction 1.
- The 2014 AHA/ACC guideline for the management of patients with valvular heart disease categorizes the stages of tricuspid regurgitation, including at risk, progressive, asymptomatic severe, and symptomatic severe 1. Regular cardiac follow-up according to standard guidelines would be appropriate, but no specific tricuspid valve-directed therapy is indicated based on this echocardiographic assessment. It is essential to prioritize the patient's quality of life, morbidity, and mortality when making treatment decisions, and in this case, the current findings do not warrant intervention 1.
From the Research
Tricuspid Valve Structure and Function
- The tricuspid valve is a complex anatomical structure that incorporates a saddle-shaped annulus, asymmetric leaflets, the subvalvular apparatus, and the right ventricle and its loading conditions 2
- The valve is dynamic and changing, making it difficult to analyze, and three-dimensional imaging, cardiac magnetic resonance imaging, and computed tomography scans may add to two-dimensional transthoracic and transoesophageal echocardiographic data in the analysis of tricuspid regurgitation (TR) 3
Tricuspid Regurgitation
- TR is present in 1.6 million individuals in the United States and 3.0 million people in Europe, and functional TR is the most common form, caused by cardiomyopathies, LV valve disease, or pulmonary disease 4
- Severe TR is a complex condition of the right ventricle and tricuspid valve apparatus, frequently associated with symptomatic heart failure and significant morbidity and mortality 5
- TR is functional and is a satellite of left-sided heart disease and/or elevated pulmonary artery pressure most of the time, and a particular form is characterized by TR worsening after left-sided valve surgery, which has been shown to impair patient prognosis 3
Diagnosis and Treatment
- Echocardiography can assess the TR etiology/severity, measure RA and RV size and function, estimate pulmonary pressure, and characterize LV disease 4
- Management includes diuretics, ACE inhibitors, and aldosterone antagonists, and surgical annuloplasty or valve replacement should be considered in patients with progressive RV dilatation without severe LV dysfunction and pulmonary hypertension 4
- Transcatheter repair/replacement is possible in patients with a LVEF <40%, dilated annuli, and impaired RV function, and transcatheter tricuspid valve repair/replacement is an emerging therapy for high-risk patients with TR who would otherwise have a dismal clinical prognosis 4, 6
Treatment Options
- Transcatheter techniques used in the treatment of valvular heart disease have evolved, lowering the risk of intervention, and allowing for safer valve repair or replacement 6
- Multiple innovative treatment concepts are currently under preclinical and clinical investigation to replace or repair TV function, but up to date, none of these approaches is established, and there is still a lack of clinical data to support the efficacy of transcatheter TR treatment 5