What are the indications for surgery in secondary tricuspid (tricuspid valve) regurgitation?

From the Guidelines

Surgery for secondary tricuspid regurgitation is indicated when patients have severe tricuspid regurgitation with symptoms or signs of right heart failure despite optimal medical therapy, or when left-sided valve surgery is already planned. Specific indications include severe tricuspid regurgitation with symptoms such as peripheral edema, ascites, or fatigue; progressive right ventricular dilation or dysfunction; tricuspid annular dilation ≥40 mm or >21 mm/m² regardless of regurgitation severity when undergoing left-sided valve surgery; and previous left-sided valve surgery with subsequent severe tricuspid regurgitation causing right heart failure.

Key Indications for Surgery

• Severe tricuspid regurgitation with symptoms or signs of right heart failure despite optimal medical therapy
• Left-sided valve surgery is already planned
• Tricuspid annular dilation ≥40 mm or >21 mm/m² regardless of regurgitation severity when undergoing left-sided valve surgery
• Previous left-sided valve surgery with subsequent severe tricuspid regurgitation causing right heart failure Surgery should also be considered in moderate tricuspid regurgitation with annular dilation when performing left-sided valve surgery, as stated in the European Society of Cardiology guidelines 1. The timing of intervention is crucial, as waiting until severe right ventricular dysfunction occurs leads to poorer outcomes, as noted in the 2014 AHA/ACC guideline for the management of patients with valvular heart disease 1.

Rationale for Early Intervention

• Tricuspid regurgitation often progresses after mitral or aortic valve surgery
• A second operation carries significantly higher risk Surgical options include tricuspid annuloplasty (preferred for most secondary cases) or valve replacement when the valve tissue is significantly damaged, as recommended in the guidelines on the management of valvular heart disease (version 2012) 1. Preoperative optimization with diuretics to reduce congestion and careful perioperative management are essential for successful outcomes. The most recent and highest quality study, a systematic review of clinical practice guidelines and recommendations published in the European Heart Journal in 2022 1, supports these indications and recommendations for surgery in secondary tricuspid regurgitation.

From the Research

Indications for Surgery in Secondary Tricuspid Regurgitation

• The decision to perform surgery for secondary tricuspid regurgitation is based on several factors, including the severity of the regurgitation, the presence of symptoms, and the patient's overall health status 2, 3.
• Patients with severe secondary tricuspid regurgitation who are undergoing left-sided valve surgery should be considered for tricuspid valve repair or replacement 2.
• Early intervention, before severe right ventricle dysfunction and pulmonary hypertension, seems to result in better postoperative outcomes 3.
• Surgical techniques, such as ring annuloplasty, can be effective in treating secondary tricuspid regurgitation, especially in patients with isolated annular dilatation 2, 4.
• Transcatheter tricuspid valve interventions (TTVIs) have emerged as an attractive treatment option for high-risk patients with tricuspid regurgitation, offering significant improvement in tricuspid regurgitation severity, functional class, and quality of life 5, 6.

Patient Selection for Surgery

• Patients with progressive right ventricular dilatation without severe left ventricular dysfunction and pulmonary hypertension should be considered for surgical annuloplasty or valve replacement 5.
• Patients with a left ventricular ejection fraction (LVEF) <40%, dilated annuli, and impaired right ventricular function may be candidates for transcatheter repair or replacement 5.
• The mechanism of tricuspid regurgitation, such as annular dilation or leaflet prolapse, should be taken into account when selecting the surgical approach 4.

Surgical Techniques and Outcomes

• Ring annuloplasty is a durable and effective technique for treating secondary tricuspid regurgitation, especially in patients with isolated annular dilatation 2, 4.
• Valve replacement with a bioprosthesis may be necessary in patients with severe tricuspid regurgitation and significant leaflet tethering or other complex valve pathology 4.
• Transcatheter tricuspid valve interventions (TTVIs) have shown excellent rates of technical success and acceptable safety outcomes, with significant improvement in tricuspid regurgitation severity and quality of life 6.