What is the recommended approach for tricuspid regurgitation repair in patients with moderate pulmonary hypertension?

Tricuspid Regurgitation Repair in Moderate Pulmonary Hypertension

Tricuspid valve repair may be considered for patients with moderate functional tricuspid regurgitation and pulmonary artery hypertension at the time of left-sided valve surgery. 1

Diagnostic Assessment

Before determining the appropriate approach for tricuspid regurgitation (TR) repair in patients with moderate pulmonary hypertension (PH), a thorough evaluation is essential:

• Imaging assessment:

  • Transthoracic echocardiography (TTE) to evaluate TR severity, etiology, right ventricular (RV) size and function, and estimate pulmonary artery systolic pressure 1
  • Consider 3D echocardiography or cardiac MRI for more accurate assessment of RV volumes and function in cases with suboptimal 2D images 2
  • Assess TR severity using established criteria (vena contracta width >0.7 cm, dense triangular CW Doppler signal) 2

• Hemodynamic assessment:

  • Invasive measurement of pulmonary artery pressures and pulmonary vascular resistance is useful when clinical and noninvasive data are discordant 1
  • This helps differentiate between fixed pulmonary hypertension and potentially reversible forms

Management Algorithm for TR with Moderate PH

1. Concomitant Left-Sided Valve Surgery Scenarios

• When undergoing left-sided valve surgery:
  • Class I (Recommended): Perform tricuspid valve surgery for severe primary or secondary TR 1
  • Class IIa (Should be considered): Perform tricuspid valve repair for moderate primary TR 1
  • Class IIa (Should be considered): Perform tricuspid valve repair for mild or moderate secondary TR with dilated annulus (≥40 mm or >21 mm/m²) 1
  • Class IIb (May be considered): Perform tricuspid valve repair specifically for moderate functional TR with pulmonary artery hypertension 1

2. Isolated TR with Moderate PH

• For symptomatic severe primary TR:

  • Class I (Recommended): Tricuspid valve surgery if symptoms are unresponsive to medical therapy and patient does not have severe RV dysfunction 1

• For asymptomatic or minimally symptomatic severe primary TR:

  • Class IIa (Should be considered): Surgery if there is progressive RV dilation or deterioration of RV function 1

• For severe secondary TR with moderate PH:

  • Class IIa (Should be considered): Surgery in symptomatic patients or those with progressive RV dilation/dysfunction, provided they don't have severe left ventricular dysfunction, severe RV dysfunction, or severe pulmonary vascular disease 1

3. Medical Management Considerations

• Diuretics to reduce congestion in symptomatic patients 1, 2
• Consider medical therapies to reduce elevated pulmonary artery pressures and/or pulmonary vascular resistance in patients with severe functional TR 1
• Rhythm control strategies for patients with atrial fibrillation 2

Surgical Approach

When tricuspid valve repair is indicated in the setting of moderate PH:

• Preferred technique: Tricuspid valve repair with a prosthetic ring is the first-line approach 1
• Ring annuloplasty: Rigid or semi-rigid ring annuloplasty is the gold standard for secondary TR 2
• Valve replacement considerations: If the tricuspid valve is significantly deformed or there are advanced forms of leaflet tethering and RV dilatation, valve replacement should be considered 1
• Bioprosthetic preference: The use of large bioprostheses over mechanical valves is currently favored for replacement 1

Risk Assessment and Contraindications

Carefully assess the following high-risk features:

• Pre-operative TV tethering height >8 mm (important determinant of recurrence after repair) 2
• Irreversible RV dysfunction 2
• Very large annuli with significant leaflet tethering 2
• Irreversible liver cirrhosis (absolute contraindication) 2

Emerging Options

For patients at high surgical risk:

• Transcatheter tricuspid valve interventions may be considered in inoperable patients at specialized heart valve centers 2, 3
• Early data from the TriValve registry suggests that transcatheter approaches can be successful even in patients with RV dysfunction or PH, with 80.7% procedural success 3

Important Caveats

• Delaying surgery in symptomatic severe TR can lead to irreversible RV damage and poor surgical outcomes 1
• The discordance between echocardiographic and invasive measurements of pulmonary pressure in TR patients can affect outcomes after intervention 4
• Combined procedures (such as tricuspid repair with lung transplantation) may be considered in end-stage pulmonary hypertension cases 5
• Procedural success is a key determinant of outcomes, regardless of baseline RV dysfunction or PH severity 3