What are the guidelines for managing tricuspid regurgitation?

Management of Tricuspid Regurgitation

Tricuspid valve surgery is indicated in symptomatic patients with severe primary tricuspid regurgitation without severe right ventricular dysfunction, and should be considered in patients with moderate tricuspid regurgitation undergoing left-sided valve surgery. 1, 2

Diagnostic Evaluation

Proper assessment of tricuspid regurgitation (TR) requires:

• Echocardiography: Essential for evaluating TR severity, etiology, right ventricular size and function 2

  • Severe TR criteria: central jet ≥50% of right atrium, dense continuous wave Doppler signal, vena contracta ≥7 mm, PISA radius >9 mm, hepatic vein systolic flow reversal, EROA ≥0.4 cm², regurgitant volume ≥45 mL/beat
  • Distinguish between primary (due to valve abnormalities) and secondary (functional) TR

• Right ventricular assessment: Critical for management decisions

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

• Right heart catheterization: When clinical and non-invasive data are discordant, to assess pulmonary pressures and resistance 2

Treatment Algorithm

1. Medical Management

• Loop diuretics: First-line therapy for symptomatic TR with congestion 2
• Aldosterone antagonists: Particularly beneficial for hepatic congestion 2
• Blood pressure control: Target 120-129/70-79 mmHg if tolerated 2
• Regular monitoring: Blood pressure, electrolytes, renal function, TR severity, and RV function 2

2. Surgical Intervention

Primary Tricuspid Regurgitation:

• Class I indication: Surgery for symptomatic patients with severe primary TR without severe RV dysfunction 1, 2
• Class IIa indication: Surgery for asymptomatic or mildly symptomatic patients with severe isolated primary TR and progressive RV dilatation or deterioration of RV function 1

Secondary Tricuspid Regurgitation:

• Class IIa indication: Surgery for patients with moderate TR undergoing left-sided valve surgery 1
• Class IIa indication: Surgery for patients with severe secondary TR who are symptomatic or have RV dilatation, without severe RV dysfunction or severe pulmonary hypertension 2

3. Surgical Techniques

• Tricuspid valve repair with annuloplasty ring: Preferred technique 2

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

• Valve replacement: Consider when the valve is significantly deformed, there is advanced leaflet tethering, or significant RV dilatation 2

  • Bioprosthetic valves are preferred over mechanical valves due to lower thrombosis risk and satisfactory durability 1

4. Transcatheter Interventions

• Class IIb indication: Transcatheter treatment may be considered in symptomatic patients with severe secondary TR who are inoperable, but only at specialized heart valve centers 2
• Emerging options include edge-to-edge repair, annuloplasty devices, and transcatheter valve replacement 3

Important Considerations and Pitfalls

• Timing is critical: Delaying surgery in symptomatic severe TR can lead to irreversible RV damage and poor outcomes 2

• Absolute contraindications for surgery:

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

• High-risk features for surgery:

  • Pre-operative TV tethering height >8 mm
  • Irreversible RV dysfunction
  • Advanced pulmonary hypertension 2

• Prognostic factors: The TRI-SCORE can help predict in-hospital mortality after isolated TV surgery, considering factors like age, NYHA class, right-sided heart failure, and renal dysfunction 2

• Combined valve disease: When TR is combined with other valve lesions, management should focus on the predominant lesion, with consideration of the interaction between different valve lesions 1