What is the best management approach for a patient with severe tricuspid regurgitation (TR) and dyspnea?

Management of Severe Tricuspid Regurgitation with Dyspnea

For patients with severe tricuspid regurgitation (TR) and dyspnea, diuretic therapy should be initiated as first-line treatment to manage right-sided heart failure symptoms, while surgical or transcatheter intervention should be considered in symptomatic patients without severe right ventricular dysfunction or irreversible pulmonary hypertension. 1

Initial Medical Management

• Loop diuretics are the cornerstone of initial therapy for symptomatic TR with congestion 2, 1

  • Effectively reduces systemic and hepatic congestion
  • Alleviates dyspnea and other symptoms of right heart failure

• Aldosterone antagonists (e.g., spironolactone) provide additional benefits 1:

  • Particularly effective for hepatic congestion commonly seen in TR
  • Less likely to worsen lymphedema compared to traditional diuretics

• Regular monitoring is essential during medical therapy 1:

  • Blood pressure, electrolytes, and renal function
  • TR severity via echocardiography
  • Lymphedema status and symptoms
  • Right ventricular function

Surgical Intervention

Surgical intervention should be considered in the following scenarios:

1. Symptomatic patients with severe primary TR without severe RV dysfunction (Class I C) 1

   • Surgery is recommended before irreversible RV damage occurs

2. Patients with severe secondary TR who are symptomatic or have RV dilatation (Class IIa B) 1

   • Important exclusion criteria: absence of severe RV dysfunction and severe pulmonary vascular disease/hypertension

3. Asymptomatic patients with isolated severe primary TR and progressive RV dilation or systolic dysfunction (Class IIb C) 1

Surgical Approach

• Tricuspid valve repair with annuloplasty ring is the preferred technique 1

  • Rigid or semi-rigid rings provide better long-term outcomes than flexible bands 2

• Valve replacement should be considered if 1:

  • The tricuspid valve is significantly deformed
  • There are advanced forms of leaflet tethering
  • Significant right ventricular dilatation is present
  • Bioprosthetic valves are preferred over mechanical valves

Transcatheter Options

• Transcatheter treatment of symptomatic severe secondary TR may be considered in inoperable patients (Class IIb C) 1
  • Should be performed at specialized heart valve centers with expertise in TV disease
  • Emerging as an alternative for high-surgical-risk patients

Important Considerations and Pitfalls

• Delaying intervention in symptomatic severe TR can lead to irreversible right ventricular damage and poor outcomes 1, 3

  • Mean survival from diagnosis of severe TR is approximately 4.35 years 3
  • Heart failure is the most common cause of death (50%) 3

• Absolute contraindications for surgery 1:

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

• High-risk features for surgery 1:

  • Pre-operative TV tethering height >8 mm
  • Irreversible RV dysfunction
  • Advanced pulmonary hypertension

• Atrial fibrillation is commonly associated with TR (70.5% of patients) 3 and should be managed appropriately

Special Considerations

• Idiopathic TR carries a worse prognosis compared to other etiologies (adjusted HR 1.83,95% CI 1.05-3.21) 4

• Isolated TR significantly worsens survival when left untreated 5

  • Low-risk patients with symptomatic severe isolated TR should be considered for intervention before the onset of RV dysfunction

• Rheumatic TR may require valve replacement rather than repair due to valve thickening and structural abnormalities 6

Despite the high morbidity and mortality associated with severe TR, only a small percentage of patients (5.3%) undergo tricuspid valve surgery 4, highlighting the importance of appropriate patient selection and timely referral for intervention.