What is the management of tricuspid valve regurgitation?

Management of Tricuspid Valve Regurgitation

Medical therapy is the first-line approach for patients with tricuspid regurgitation (TR) and right-sided signs and symptoms of heart failure, but should not delay referral for surgery or transcatheter therapy when already indicated. 1, 2

Diagnostic Evaluation

Echocardiographic Assessment

• Evaluate 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 2

Right Ventricular Assessment

• Evaluate RV size and function
• Consider cardiac MRI or 3D echocardiography for more accurate assessment
• RV free wall longitudinal strain may be used to assess RV systolic function 2

Hemodynamic Assessment

• Right heart catheterization is recommended when clinical and non-invasive data are discordant
• Measure systolic pulmonary artery pressure, pulmonary vascular resistance, and right atrial pressure 2

Treatment Algorithm

1. Medical Therapy

• Loop diuretics to reduce systemic and hepatic congestion (first-line for symptomatic TR with congestion)
• Aldosterone antagonists for additional benefit, especially with hepatic congestion
• Guideline-directed medical therapy for heart failure with reduced ejection fraction
• Rhythm control in patients with atrial fibrillation
• Specific pulmonary hypertension treatment if applicable 2

2. Surgical Intervention

• Indications for primary TR:

  • Class I: Symptomatic patients with severe primary TR without severe RV dysfunction
  • Class IIb: Asymptomatic patients with isolated severe primary TR and progressive RV dilation or systolic dysfunction 2

• Indications for secondary TR:

  • Class IIa: Patients with severe secondary TR who are symptomatic or have RV dilatation, without severe RV dysfunction and severe pulmonary vascular disease/hypertension 2
  • Consider TV repair during left-sided heart valve surgery even with moderate TR or tricuspid annular dilation 1

• Surgical approach:

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

3. Transcatheter Treatment

• May be considered in symptomatic patients with severe secondary TR who are inoperable
• Should be performed at a heart valve center with expertise in TV disease 2
• Emerging as an alternative for high-risk patients, but still in early development stages 3, 4

High-Risk Features and Contraindications

• Absolute contraindications for surgery:

  • Irreversible liver cirrhosis 2
  • Severe RV dysfunction with very large annuli and significant leaflet tethering 1

• High-risk features:

  • Pre-operative TV tethering height >8 mm (predictor of recurrence after repair)
  • Irreversible RV dysfunction
  • Advanced pulmonary hypertension 2

Follow-up and Outcomes

• Regular echocardiographic surveillance is essential
• Severe TR is associated with worse outcomes, including shorter 6-minute walk distances, higher BNP levels, and greater right atrial and RV dilatation 2
• Delaying surgery in symptomatic severe TR can lead to irreversible RV damage, organ failure, and poor surgical outcomes 2

Important Considerations

• Early detection and intervention are crucial before development of irreversible RV dysfunction
• The gold standard surgical treatment for secondary TR is rigid or semirigid ring annuloplasty 1
• Conservative management is recommended in asymptomatic patients with severe primary TR but non-dilated RV 1
• Conservative management is also recommended in symptomatic patients with severe secondary TR and either severe RV dysfunction or irreversible pulmonary hypertension 1