What is the management of severe tricuspid regurgitation (TR) with right ventricular (RV) dysfunction?

Management of Severe Tricuspid Regurgitation with Right Ventricular Dysfunction

Medical therapy should be the first-line approach for severe tricuspid regurgitation (TR) with right ventricular (RV) dysfunction, with surgical intervention generally avoided in the presence of severe RV dysfunction due to poor outcomes. 1, 2

Initial Medical Management

• Diuretic therapy:

  • Loop diuretics to reduce systemic and hepatic congestion (Class IIa C-EO) 1
  • Aldosterone antagonists for additional benefit, especially with hepatic congestion 2

• Guideline-directed medical therapy (GDMT):

  • For heart failure with reduced ejection fraction (Class IIa C-EO) 1
  • First-line treatment in both primary and secondary TR 1

• Treatment of underlying conditions:

  • Rhythm control in patients with atrial fibrillation 1
  • Specific pulmonary hypertension treatment if applicable 1

Diagnostic Assessment

• Echocardiographic evaluation:

  • Assess TR severity using established criteria:

    • Central jet ≥50% of right atrium
    • Dense continuous wave Doppler signal with triangular shape
    • Vena contracta ≥7 mm
    • PISA radius >9 mm
    • Hepatic vein systolic flow reversal
    • EROA ≥0.4 cm²
    • Regurgitant volume ≥45 mL/beat 1

  • Evaluate RV size and function:

    • Consider cardiac MRI or 3D echocardiography for more accurate assessment 1, 2
    • RV free wall longitudinal strain may be considered to assess RV systolic function (Class IIb C) 1

• Hemodynamic assessment:

  • Right heart catheterization to measure systolic pulmonary artery pressure, pulmonary vascular resistance, and right atrial pressure when clinical and non-invasive data are discordant (Class IIa C) 1

Surgical Intervention Considerations

For patients with severe TR and RV dysfunction, surgical options are limited by the following guidelines:

• Primary TR:

  • TV surgery is recommended in symptomatic patients with isolated severe primary TR without severe RV dysfunction (Class I C) 1
  • In asymptomatic patients with isolated severe primary TR and progressive RV dilation or systolic dysfunction, TV surgery may be considered (Class IIb C) 1

• Secondary TR:

  • TV surgery should be considered in patients with severe secondary TR who are symptomatic or have RV dilatation, in the absence of severe RV dysfunction and severe pulmonary vascular disease/hypertension (Class IIa B) 1
  • In refractory right-sided HF, severe TR, and previous left-sided valve surgery, reoperation with isolated TV surgery may be considered in the absence of severe RV systolic dysfunction (Class IIb B-NR) 1

Transcatheter Options

• For inoperable patients:
  • Transcatheter treatment of symptomatic secondary severe TR may be considered in inoperable patients at a heart valve center with expertise in TV disease (Class IIb C) 1
  • Transcatheter edge-to-edge repair (TEER) is emerging as a promising solution for patients with severe TR at high surgical risk 3

Risk Assessment and Contraindications

• High-risk features to identify:

  • Irreversible RV dysfunction
  • Liver dysfunction (assess using Child-Pugh classification and MELD score)
  • Advanced pulmonary hypertension 1
  • Anemia and renal dysfunction 4

• Contraindications:

  • Irreversible liver cirrhosis is an absolute contraindication for surgery 1
  • Pre-operative TV tethering height >8 mm is an important determinant of recurrence after TV repair 1

Timing of Intervention

• Timely intervention before the development of severe RV dysfunction is crucial
• Delaying surgery in symptomatic severe TR can lead to irreversible RV damage, organ failure, and poor surgical outcomes 2, 4
• Patients with severe isolated TR should be considered for intervention before the onset of anemia, organ dysfunction, or significant RV dilatation 4

Follow-up

• Regular echocardiographic surveillance to monitor:
  • RV function
  • TR severity
  • Development of other cardiac abnormalities 2
• Adjust medical therapy as needed based on symptoms and clinical status

The management of severe TR with RV dysfunction requires careful consideration of the extent of RV dysfunction, as severe RV dysfunction significantly worsens surgical outcomes and may contraindicate surgical intervention.