From the Guidelines
Tricuspid regurgitation should be managed with a focus on reducing symptoms and preventing disease progression, with surgical intervention considered for severe symptomatic cases, as stated in the 2023 ACC/AHA/SCAI advanced training statement on interventional cardiology 1.
Key Considerations
- Tricuspid regurgitation is a condition where the tricuspid valve doesn't close properly, allowing blood to flow backward from the right ventricle into the right atrium during contraction.
- Management depends on symptoms and underlying causes, with treatment typically including diuretics, ACE inhibitors, and beta-blockers to control heart rate and reduce fluid retention.
- Severe symptomatic cases may require surgical intervention, including valve repair or replacement, as recommended in the 2014 AHA/ACC guideline for the management of patients with valvular heart disease 1.
Treatment Approach
- Diuretics like furosemide (20-80mg daily) can help reduce fluid retention.
- ACE inhibitors such as enalapril (2.5-20mg twice daily) can decrease afterload.
- Beta-blockers like metoprolol (25-200mg daily) can control heart rate.
- Surgical intervention, including valve repair or replacement, may be necessary for severe symptomatic cases.
Monitoring and Lifestyle Modifications
- Regular echocardiographic monitoring is essential to track disease progression and adjust treatment accordingly.
- Lifestyle modifications, including sodium restriction, moderate exercise as tolerated, and weight management, are also important components of management.
Important Considerations for Surgical Intervention
- Correction of symptomatic severe primary tricuspid regurgitation (stage D) is preferentially performed before onset of significant right ventricular dysfunction.
- Replacement may be required due to the extent and severity of the underlying pathology.
- Reduction or elimination of the regurgitant volume load can alleviate systemic venous and hepatic congestion and decrease reliance on diuretics.
From the Research
Definition and Prevalence of Tricuspid Regurgitation
- Tricuspid regurgitation (TR) is a condition affecting approximately 1.6 million individuals in the United States and 3.0 million people in Europe 2.
- Significant TR is a common finding, affecting about one in twenty-five subjects among the elderly, and presents more frequently in women than in men 3.
Etiology and Pathophysiology
- Functional TR, the most common form of TR, is caused by cardiomyopathies, LV valve disease, or pulmonary disease 2.
- TR can be distinguished as primary and secondary or functional TR (FTR), with FTR being the most prevalent 3.
- FTR is a multifactorial disorder, resulting from maladaptive right ventricular remodeling secondary to pulmonary hypertension or from atrial fibrillation leading to dilation of the right atrium, tricuspid annulus, and base of the right ventricle, with pathological TV coaptation 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 2.
- Management includes diuretics, ACE inhibitors, and aldosterone antagonists 2.
- Surgical annuloplasty or valve replacement should be considered in patients with progressive RV dilatation without severe LV dysfunction and pulmonary hypertension 2.
- Transcatheter repair/replacement is possible in patients with a LVEF <40%, dilated annuli, and impaired RV function 2.
- Transcatheter tricuspid valve repair/replacement is an emerging therapy for high-risk patients with TR who would otherwise have a dismal clinical prognosis 2, 4, 5.
Prognosis and Outcomes
- The five-year survival with severe TR and HFrEF is 34% 2.
- Severe TR is associated with symptomatic heart failure and significant morbidity and mortality 4.
- A diuretic response is associated with the early prognosis of patients undergoing repeat tricuspid valve surgery due to severe tricuspid regurgitation after left-sided valvular surgery 6.