What is the treatment for Tricuspid Valve Disease (TVD)?

Treatment of Tricuspid Valve Disease (TVD)

Surgery is indicated for patients with severe tricuspid regurgitation or stenosis, with valve repair preferred over replacement whenever possible. 1

Diagnostic Evaluation

• Echocardiography is essential for diagnosis and characterization of TVD:

  • Assess severity of regurgitation/stenosis
  • Evaluate right ventricular size and function
  • Measure tricuspid annular dimensions (significant if ≥40 mm or >21 mm/m²) 1
  • Evaluate for associated left-sided valve disease

• Advanced imaging may be necessary:

  • Cardiac MRI or 3D echocardiography for accurate RV assessment 2
  • RV free wall longitudinal strain to assess RV systolic function 2

• Right heart catheterization when clinical and non-invasive data are discordant 2

Treatment Algorithm for Tricuspid Regurgitation (TR)

1. Medical Management

• Diuretics are first-line therapy for symptomatic TR with congestion 1, 2

  • Loop diuretics to reduce systemic and hepatic congestion
  • Aldosterone antagonists for additional benefit, especially with hepatic congestion

• Specific pulmonary hypertension treatment if applicable to reduce RV afterload and functional TR 1, 2

• Rhythm control in patients with atrial fibrillation 2

2. Surgical Management

Primary TR

• Surgery indicated for:
  • Symptomatic patients with severe primary TR without severe RV dysfunction (Class I) 1
  • Asymptomatic patients with progressive RV dilation or deterioration of RV function (Class IIa) 1

Secondary TR

• Surgery indicated for:
  • Severe TR in patients undergoing left-sided valve surgery (Class I) 1
  • Moderate or greater TR with tricuspid annular dilation or prior evidence of right HF at time of left-sided valve surgery (Class IIa) 1
  • Symptomatic patients with severe TR or those with RV dilation without severe RV dysfunction or severe pulmonary hypertension (Class IIa) 1

Tricuspid Stenosis

• Surgery indicated for:
  • Symptomatic patients with severe TS (Class I) 1
  • Patients with severe TS undergoing left-sided valve surgery (Class I) 1

3. Surgical Techniques

• Valve repair is preferable to valve replacement when feasible 1, 2

  • Ring annuloplasty (rigid or semi-rigid) is the gold standard for secondary TR 2
  • Suture annuloplasty or partial ring annuloplasty can give satisfactory results 3

• Valve replacement when:

  • Tricuspid valve leaflets are significantly tethered 1
  • Annulus is severely dilated 1
  • Valve repair is not feasible due to extensive leaflet damage 3
  • Bioprosthetic valves are generally preferred over mechanical valves 1, 2

4. Transcatheter Interventions

• Consider for high-risk surgical patients 4, 5
  • Transcatheter edge-to-edge repair (e.g., TriClip) for high-risk patients 4
  • Other options include coaptation devices, annuloplasty devices, and transcatheter valve prostheses 2, 5
  • May be considered in inoperable symptomatic patients with severe secondary TR (Class IIb) 2

High-Risk Features

• Pre-operative TV tethering height >8 mm 2
• Irreversible RV dysfunction 2
• Advanced pulmonary hypertension 2
• Severe RV dysfunction with very large annuli and significant leaflet tethering 2
• Irreversible liver cirrhosis 2

Prognosis and Follow-up

• Severe TR is associated with worse outcomes, including shorter 6-minute walk distances and greater right atrial and RV dilatation 2
• Regular echocardiographic surveillance is essential for monitoring disease progression and RV function 2

Common Pitfalls

1. Delayed intervention - Waiting too long can lead to irreversible RV damage and poor surgical outcomes 2
2. Overlooking moderate TR during left-sided valve surgery - Can progress over time in approximately 25% of patients 1
3. Inadequate assessment of RV function - Critical for determining surgical candidacy and timing
4. Focusing solely on left-sided valve disease - TVD is often secondary but requires specific attention and treatment

The management of TVD has evolved substantially, with increasing recognition of its impact on morbidity and mortality. Early intervention before the development of irreversible RV dysfunction is crucial for optimal outcomes.