What are the management guidelines for acute tricuspid regurgitation?

Management of Acute Tricuspid Regurgitation

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

Diagnostic Evaluation

Accurate assessment of TR severity and etiology is crucial for management decisions:

• Transthoracic echocardiography (TTE) is the primary diagnostic tool to:

  • 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 valve morphology and determine etiology
  • Measure right chamber size and function
  • Estimate pulmonary artery pressure

• Advanced imaging when needed:

  • 3D transoesophageal echocardiography for detailed anatomical assessment
  • Cardiovascular magnetic resonance for accurate RV volumetric analysis 2
  • Right heart catheterization when clinical and non-invasive data are discordant 1

Medical Management

Medical therapy is indicated for patients with TR and signs of right-sided heart failure:

1. Loop diuretics are first-line therapy to reduce systemic and hepatic congestion 1
2. Aldosterone antagonists should be considered for additional benefit, especially with hepatic congestion 1
3. Guideline-directed medical therapy for heart failure with reduced ejection fraction 1
4. Rhythm control in patients with atrial fibrillation 1
5. Specific pulmonary hypertension treatment if applicable 1

Surgical Management

Primary Tricuspid Regurgitation:

• Surgery is indicated for:
  • Symptomatic patients with severe primary TR without severe RV dysfunction (Class I) 1
  • Asymptomatic patients with isolated severe primary TR and progressive RV dilation or dysfunction (Class IIb) 1

Secondary Tricuspid Regurgitation:

• Surgery should be considered for:
  • Patients with severe secondary TR who are symptomatic or have RV dilatation (Class IIa) 1
  • Patients with moderate TR or tricuspid annular dilation undergoing left-sided heart valve surgery (Class IIa) 2, 1

Surgical Techniques:

• Tricuspid valve repair is preferred over replacement when feasible 1
• Rigid or semi-rigid ring annuloplasty is the gold standard for secondary TR 1

Transcatheter Interventions

• Transcatheter treatment may be considered in symptomatic patients with severe TR who are inoperable (Class IIb) 1
• Several clinical trials are evaluating transcatheter devices including:
  • Coaptation devices
  • Annuloplasty devices
  • Transcatheter valve prostheses 2

Contraindications and High-Risk Features

Absolute contraindications for surgery:

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

High-risk features:

• Pre-operative TV tethering height >8 mm (predictor of recurrence after repair) 1
• Irreversible RV dysfunction
• Advanced pulmonary hypertension 2, 1

Risk Stratification

The TRI-SCORE can help predict in-hospital mortality after isolated TV surgery:

• Age >70 years (+1)
• NYHA class III-IV (+1)
• Right-sided heart failure (+2)
• High-dose furosemide (+2)
• Renal dysfunction (+2)
• Elevated bilirubin (+2)
• LV dysfunction (+1)
• RV dysfunction (+1) 2

Risk categories: Low risk (<3), Intermediate risk (3-5), High risk (>5)

Follow-up

Regular echocardiographic surveillance is essential to:

• Monitor for TR progression
• Assess RV function
• Evaluate for other valvular disease progression 1

Clinical Pitfalls to Avoid

1. Delaying intervention in symptomatic severe TR can lead to irreversible RV damage, organ failure, and poor surgical outcomes 1

2. Underestimating TR severity - use multiple parameters and modalities for comprehensive assessment

3. Overlooking tricuspid annular dilation during left-sided valve surgery, which can lead to progressive TR later

4. Focusing solely on TR without addressing underlying causes (pulmonary hypertension, left-sided heart disease)

5. Misinterpreting RV function - consider advanced imaging techniques for accurate assessment