Management of Tricuspid Regurgitation in Patients with Atrial Septal Defects
In patients with atrial septal defects (ASD) and significant tricuspid regurgitation (TR), surgical ASD closure with concomitant tricuspid valve repair is strongly recommended when TR is moderate to severe, especially with symptoms or right heart enlargement. 1
Assessment of TR in ASD Patients
- Mechanism of TR in ASD: Primarily functional due to right ventricular (RV) volume overload from left-to-right shunting, leading to tricuspid annular dilation and valve leaflet tethering
- Diagnostic evaluation:
- Echocardiography to assess TR severity, tricuspid valve anatomy, and right heart chamber enlargement
- Measurement of right atrial area, RV size, and pulmonary artery pressures
- Assessment of TR jet area and tricuspid annular dimensions
Management Algorithm Based on TR Severity
Mild TR with ASD:
- ASD closure alone (device or surgical depending on ASD type) without tricuspid valve intervention
- TR often improves spontaneously after ASD closure due to reduced RV volume overload 2
Moderate TR with ASD:
Without pulmonary hypertension (PA systolic pressure <44 mmHg):
- ASD closure alone is reasonable, as TR often improves after correction 2
- Follow closely for TR regression post-closure
With pulmonary hypertension (PA systolic pressure ≥44 mmHg):
Severe TR with ASD:
- Strong recommendation for surgical ASD closure with concomitant tricuspid valve repair 1
- Tricuspid valve repair techniques include:
- Annuloplasty ring placement
- Kay's procedure (bicuspidization)
- Creation of a "monocusp valve" in cases with mobile anterior leaflet 1
Special Considerations
Ebstein's Anomaly with ASD:
- Surgical approach is preferred with repair of both the tricuspid valve and ASD closure 1
- For mild to moderate TR in Ebstein's anomaly:
- Device closure of ASD may be considered in carefully selected patients 4
- Requires careful hemodynamic assessment with balloon test occlusion before permanent closure
- Contraindicated if significant right-to-left shunting or elevated right heart pressures occur during test occlusion
Risk Factors for Persistent TR After ASD Closure:
- Age ≥60 years
- Right atrial end-diastolic area ≥10cm²/m²
- Right ventricular systolic pressure ≥44 mmHg (strongest predictor)
- Tricuspid annular plane systolic excursion ≤2.3 cm 5
Follow-up After Intervention
- Echocardiographic assessment at 3-6 months and then annually
- Monitor for:
- Residual or recurrent TR
- Right ventricular size and function
- Residual shunting
- Pulmonary artery pressures
Important Caveats
- Isolated device closure of ASD in patients with severe TR may lead to persistent TR and progressive right heart failure
- Persistent moderate/severe TR after ASD closure is associated with higher rates of adverse events including heart failure hospitalizations 5
- In patients with Ebstein's anomaly, closing an ASD without addressing severe TR can lead to increased right heart pressures and decreased cardiac output 4
- Tricuspid valve repair is preferred over replacement when feasible 1
- For secundum ASDs with significant TR, consider surgical rather than percutaneous closure to allow for concomitant tricuspid valve repair 1
By addressing both the ASD and significant TR simultaneously, outcomes regarding morbidity, mortality, and quality of life are significantly improved compared to addressing only the ASD.