From the Guidelines
The tricuspid valve function appears normal with only physiologic (trivial) regurgitation, and no intervention is required as these findings represent normal cardiac hemodynamics. The tricuspid valve assessment shows normal structure with trivial regurgitation and no stenosis. The inferior vena cava (IVC) caliber is 1.3 cm, which is within normal limits, suggesting normal right atrial pressure, as indicated by the European Society of Cardiology guidelines 1. This is confirmed by the measured right atrial pressure of 3 mmHg, which is also normal. The tricuspid regurgitation velocity is 1.2 m/s, indicating a low pressure gradient across the valve.
According to the 2014 AHA/ACC guideline for the management of patients with valvular heart disease 1, the patient's condition can be classified as Stage A, "At risk of TR", with no or trace TR, and normal valve anatomy and hemodynamics. The normal IVC size and low right atrial pressure indicate adequate right heart function without evidence of right-sided heart failure or pulmonary hypertension. The low TR velocity further confirms the absence of elevated right ventricular systolic pressure.
Key points to consider in this patient's evaluation include:
- Normal tricuspid valve structure and function
- Trivial regurgitation with no stenosis
- Normal IVC caliber and right atrial pressure
- Low tricuspid regurgitation velocity
- No evidence of right-sided heart failure or pulmonary hypertension
These parameters should be monitored during routine cardiac follow-up, but currently show no pathological changes requiring treatment, as supported by the guidelines 1.
From the Research
Tricuspid Valve Structure and Function
- The tricuspid valve is a complex structure with variable anatomy, and its appreciation is essential to understanding the pathophysiology of tricuspid regurgitation 2
- Tricuspid regurgitation (TR) is present in 1.6 million individuals in the United States and 3.0 million people in Europe, with functional TR being the most common form 3
Tricuspid Regurgitation Diagnosis and Treatment
- Echocardiography can assess the TR etiology/severity, measure RA and RV size and function, estimate pulmonary pressure, and characterize LV disease 3
- Management of TR includes diuretics, ACE inhibitors, and aldosterone antagonists, with surgical annuloplasty or valve replacement considered in patients with progressive RV dilatation without severe LV dysfunction and pulmonary hypertension 3
- Transcatheter repair/replacement is possible in patients with a LVEF <40%, dilated annuli, and impaired RV function 3
- The evaluation and management of TR are often challenging, and an evidence-based approach to diagnosis and treatment is critical 4
Disease Stages and Treatment Outcomes
- Tricuspid transcatheter edge-to-edge repair (T-TEER) has emerged as a treatment option for patients with severe TR, but randomized trials have not shown a survival benefit, possibly due to the inclusion of patients in an early or too advanced disease stage 5
- Disease stage is based on left and right ventricular function, renal function, and natriuretic peptide levels, and stratification can help identify patients who may benefit from T-TEER 5
- Mortality was significantly lower in patients undergoing percutaneous treatment with intermediate disease stage, but not at early or advanced disease stages 5
Current Understanding and Novel Treatment Options
- Managing patients with severe symptomatic TR remains challenging, with a lack of consensus on when and how to treat it 6
- Numerous surgical and transcatheter treatment options are now available, but optimal timing and procedural selection remain crucial aspects influencing outcomes 6
- Early referral is associated with good short and long-term outcomes, and various predictors of favorable outcomes following either surgical or transcatheter treatment have been identified 6