What is the management of tricuspid regurgitation?

Management of Tricuspid Regurgitation

Surgical intervention is indicated in symptomatic patients with severe isolated primary tricuspid regurgitation without severe right ventricular dysfunction, while medical therapy with diuretics is the first-line approach for patients with right-sided heart failure symptoms. 1

Diagnosis and Assessment

Echocardiographic Evaluation

• Echocardiography is essential for diagnosing TR and assessing:
  • TR severity (central jet area >10 cm², vena contracta width >0.7 cm, dense triangular CW Doppler signal) 2
  • Etiology (primary vs. secondary)
  • Tricuspid annular dilation (>40 mm or >21 mm/m²)
  • Right ventricular size and function
  • Pulmonary artery pressure estimation

Additional Imaging

• Cardiac MRI or CT should be considered when echocardiographic assessment of RV function is suboptimal 2
• Right heart catheterization is essential when pulmonary hypertension treatment is being considered 2

Management Algorithm

1. Medical Management

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

2. Surgical Management

• Indications for surgery (Class I recommendations) 1:

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

• Surgery should be considered (Class IIa recommendations) 1:

  • Patients with moderate primary TR undergoing left-sided valve surgery
  • Asymptomatic or mildly symptomatic patients with severe isolated primary TR and progressive RV dilatation or deterioration of RV function
  • Symptomatic or asymptomatic AF patients with progressive RV dysfunction and/or dilation despite medical therapy 1

• Surgical approach:

  • Tricuspid valve repair is preferred over replacement when feasible 2
  • Rigid or semi-rigid ring annuloplasty is the gold standard for secondary TR 2
  • Biological prostheses are usually preferred over mechanical ones for valve replacement due to lower thrombosis risk 1

3. Transcatheter Interventions

• Consider transcatheter tricuspid valve repair/replacement in:
  • Symptomatic patients with severe secondary TR who are inoperable or high surgical risk 2
  • Patients with LVEF <40%, dilated annuli, and impaired RV function 3

Special Considerations

Secondary TR Management

• Conservative management is recommended in:
  • Asymptomatic patients with severe primary TR but non-dilated RV
  • Symptomatic patients with severe secondary TR and either severe RV dysfunction or irreversible pulmonary hypertension 1

Timing of Intervention

• Early intervention is crucial as delaying surgery in symptomatic severe TR can lead to:
  • Irreversible RV damage
  • End-organ failure
  • Poor surgical outcomes 2

Follow-up

• Regular echocardiographic surveillance is essential for patients with TR, especially after intervention, to monitor for recurrence or progression 2
• Annual echocardiographic examinations should be performed in patients with at least moderate TR, particularly in the presence of risk factors 4

Common Pitfalls

• Underestimation of TR severity in patients with severe TR when using TRV alone 2
• Delaying intervention until RV dysfunction occurs, which significantly worsens outcomes 2, 5
• Failure to address TR at the time of left-sided valve surgery, which may lead to late TR development 6
• Inadequate assessment of RV function, which is crucial for determining surgical candidacy 1