From the Guidelines
The tricuspid valve appears to be functioning normally with only trivial regurgitation and no evidence of stenosis, and therefore, no intervention is needed at this time. The right atrial pressure is normal at 3 mmHg, and the inferior vena cava (IVC) caliber is within normal limits at 1.3 cm with normal respiratory variation of greater than 50% 1. The tricuspid regurgitation velocity is 1.2 m/s, which indicates a normal right ventricular systolic pressure (RVSP). These findings collectively suggest normal right heart hemodynamics without evidence of pulmonary hypertension or right-sided heart failure. According to the 2014 AHA/ACC guideline for the management of patients with valvular heart disease, trivial regurgitation is classified as stage A, where there is no or trace tricuspid regurgitation, and no hemodynamic consequences are present 1.
Some key points to consider in the assessment of tricuspid valve disease include:
- Valve anatomy and hemodynamics, as outlined in the guideline 1
- Clinical correlation and judgment to accompany echocardiographic results, as emphasized in the 2006 ACC/AHA guidelines for the management of patients with valvular heart disease 1
- The importance of monitoring for changes in valve function over time, particularly if symptoms develop, such as lower extremity edema, fatigue, or shortness of breath 1.
Regular cardiac follow-up with routine echocardiography is recommended to monitor for any changes in valve function over time. This approach is supported by the most recent and highest quality study, which prioritizes the assessment of tricuspid valve disease based on valve anatomy, hemodynamics, and clinical correlation 1.
From the Research
Tricuspid Valve Structure and Function
- The tricuspid valve has a broad anatomical variability, with significant tricuspid regurgitation (TR) affecting about one in twenty-five subjects among the elderly, presenting more frequently in women than in men 2.
- Tricuspid regurgitation 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, caused by cardiomyopathies, LV valve disease, or pulmonary disease 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 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, and is an emerging therapy for high-risk patients with TR who would otherwise have a dismal clinical prognosis 3, 2, 4.
Tricuspid Regurgitation Severity and Prognosis
- Significant TR leads to worsening prognosis regardless of the underlying etiology and should be addressed as a separate therapeutic target 2.
- Severe TR is associated with global morbidity and mortality of cardiovascular events, and the five-year survival with severe TR and HFrEF is 34% 3, 5.
- 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.
Treatment Options and Future Perspectives
- Several transcatheter TV replacement and repair systems have shown efficacy and safety when used on the TV, providing an effective treatment option for patients not eligible for surgery 2, 4.
- Novel transcatheter therapies have begun to emerge for the treatment of tricuspid regurgitation in patients deemed at very high or prohibitive surgical risk 4.
- Evaluation by a multidisciplinary heart team with expertise in tricuspid valve disease is of paramount importance to identify adequate treatment for every patient 6.