What is the current guideline for managing severe tricuspid regurgitation?

Management of Severe Tricuspid Regurgitation

Surgical intervention is recommended for patients with severe tricuspid regurgitation (TR) who are undergoing left-sided valve surgery, and should be considered in symptomatic patients with isolated severe TR without severe right ventricular dysfunction. 1

Classification of Tricuspid Regurgitation

TR can be classified as:

1. Primary TR: Direct valve pathology (leaflet abnormalities)

   • Rheumatic disease
   • Endocarditis
   • Congenital abnormalities (e.g., Ebstein's anomaly)
   • Carcinoid syndrome
   • Trauma
   • Iatrogenic (pacemaker leads)

2. Secondary (Functional) TR: Normal valve leaflets with annular dilation and/or leaflet tethering

   • Left-sided heart disease
   • Pulmonary hypertension
   • Right ventricular dilation
   • Atrial fibrillation

Diagnostic Evaluation

• Echocardiography: Essential for assessing TR severity, etiology, right ventricular (RV) size and function

  • Severe TR criteria: Central jet area >10 cm², vena contracta width >0.7 cm, dense triangular CW Doppler signal 1
  • Assess tricuspid annular dilation (>40 mm or >21 mm/m²)
  • Evaluate RV size and function

• Additional imaging: Consider cardiac MRI or CT for better RV assessment when echocardiography is suboptimal

Treatment Algorithm for Severe TR

1. Medical Management

• Diuretics: First-line therapy for symptomatic TR with congestion 1
  • Loop diuretics to reduce systemic and hepatic congestion
  • Consider aldosterone antagonists for additional benefit, especially with hepatic congestion 2
• Treatment of underlying conditions:
  • Rhythm control in patients with atrial fibrillation 1
  • Specific pulmonary hypertension treatment when appropriate 1
  • Guideline-directed medical therapy for heart failure with reduced ejection fraction 1

2. Surgical Intervention

Class I Recommendations (Strong) 1:

• Patients with severe TR undergoing left-sided valve surgery
• Symptomatic patients with severe isolated primary TR without severe RV dysfunction

Class IIa Recommendations (Should be considered) 1:

• Asymptomatic or mildly symptomatic patients with severe isolated primary TR and progressive RV dilation or deterioration of RV function
• Patients with moderate primary TR undergoing left-sided valve surgery
• Patients with mild or moderate secondary TR with dilated annulus (≥40 mm or >21 mm/m²) undergoing left-sided valve surgery
• Patients with severe TR who are symptomatic or have progressive RV dilation/dysfunction after previous left-sided valve surgery (in the absence of left-sided valve dysfunction, severe RV/LV dysfunction, and severe pulmonary vascular disease)

Class IIb Recommendations (May be considered) 1:

• Asymptomatic or minimally symptomatic patients with severe primary TR and progressive RV dilation/dysfunction
• Reoperation for isolated TR in patients with persistent symptoms due to severe TR after previous left-sided valve surgery (without severe pulmonary hypertension or significant RV dysfunction)

3. Transcatheter Interventions

• Transcatheter tricuspid valve repair/replacement: May be considered in symptomatic patients with severe secondary TR who are inoperable or high surgical risk 1
  • Class IIb recommendation per ESC guidelines 1
  • Should be performed at specialized heart valve centers with expertise in tricuspid valve disease 1
  • Options include edge-to-edge repair (TriClip) 3, annuloplasty devices, and valve replacement

Surgical Techniques

• Tricuspid valve repair: Preferred over replacement when feasible 1

  • Rigid or semi-rigid ring annuloplasty is the gold standard for secondary TR 1
  • Better long-term outcomes compared to flexible bands or suture annuloplasty

• Tricuspid valve replacement: Consider when repair is not feasible

  • Biological prostheses generally preferred over mechanical due to lower thrombosis risk 1

Important Considerations and Pitfalls

1. Don't delay intervention: Delaying surgery in symptomatic severe TR can lead to irreversible RV damage, organ failure, and poor surgical outcomes 1

2. Assess RV function carefully: Outcomes are poor in patients with severe RV dysfunction, very large annuli, and significant leaflet tethering 1

3. Consider concomitant procedures: TR is often associated with left-sided valve disease and should be addressed during left-sided valve surgery 1

4. Recognize high-risk features:

   • Pre-operative TV tethering height >8 mm predicts recurrence after repair 1
   • Irreversible liver cirrhosis is a contraindication for surgery 1
   • Severe RV dysfunction, liver dysfunction, and advanced pulmonary hypertension require careful assessment 1

5. Follow-up: Regular echocardiographic surveillance is essential for patients with TR, especially after intervention, to monitor for recurrence or progression

By following this structured approach to severe TR management, clinicians can optimize outcomes for patients with this challenging valvular condition.