What are the treatment options for severe Tricuspid Regurgitation (TR)?

From the Guidelines

Severe tricuspid regurgitation (TR) requires prompt intervention, with treatment options including medical management and surgical repair or replacement, and the most recent guidelines suggest that transcatheter tricuspid valve interventions are emerging as less invasive options for high-surgical-risk patients 1.

Medical Management

Initial medical therapy focuses on diuretics like furosemide (20-80mg daily) to manage fluid overload and symptoms, along with aldosterone antagonists such as spironolactone (25-50mg daily) for additional diuresis and anti-remodeling effects, as recommended by the 2014 AHA/ACC guideline for the management of patients with valvular heart disease 1.

• Diuretics can be useful for patients with severe TR and signs of right-sided HF (stage D) 1.
• Aldosterone antagonists may be of additive benefit, especially in the setting of hepatic congestion, which may promote secondary hyperaldosteronism 1.

Surgical Intervention

Definitive treatment for severe TR typically requires surgical intervention, either through valve repair (annuloplasty, leaflet repair) or valve replacement (bioprosthetic or mechanical valves), and the 2017 ESC/EACTS guidelines recommend surgery for symptomatic patients with severe tricuspid stenosis or regurgitation 1.

• Tricuspid valve surgery is recommended for patients with severe TS at the time of operation for left-sided valve disease 1.
• Tricuspid valve surgery is recommended for patients with isolated, symptomatic severe TS 1.

Transcatheter Tricuspid Valve Interventions

Transcatheter tricuspid valve interventions are emerging as less invasive options for high-surgical-risk patients, and the 2023 ACC/AHA/SCAI advanced training statement on interventional cardiology recommends that interventional cardiologists be familiar with the clinical presentation, diagnosis, and management of tricuspid valve disease 1.

• Transcatheter tricuspid valve interventions may provide patients with an alternative option to surgery, but clinicians must be more attuned to the medical and surgical management of patients with tricuspid valve disease 1.
• The optimal modalities and timing for TV surgery have yet to be fully clarified, and transcatheter tricuspid valve interventions are still poorly recommended in European guidelines and not present in American guidelines 1.

Treatment Decisions

Treatment decisions should consider the etiology of TR (primary vs. secondary), presence of other valve disease, right ventricular function, and the patient's overall clinical status, and early referral to a cardiac surgeon or interventional cardiologist is recommended once severe TR is diagnosed, particularly if symptoms are present or right ventricular enlargement is detected 1.

• The timing of intervention is crucial, as waiting until right ventricular dysfunction develops can lead to poorer outcomes 1.
• Optimal medical treatment has not yet been uniquely defined for right-sided HF, and further research is needed to investigate the usefulness of cardiac magnetic resonance imaging in assessing TR severity and defining RV dysfunction 1.

From the Research

Treatment Options for Severe Tricuspid Regurgitation (TR)

• Surgical treatment options are available for severe TR, although the ideal time for these treatments is not well-defined 2
• Transcatheter interventions, including transcatheter tricuspid valve repair and replacement, are emerging as promising treatment options for severe TR 3, 4, 5
• Transcatheter tricuspid valve replacement is rapidly emerging and may ultimately become the preferred treatment option for some patients 3
• Medical therapy for right-sided heart failure, which is often associated with TR, is limited 2
• Optimal management of symptomatic severe TR requires a comprehensive approach, including assessment and management of coexisting conditions, and consideration of the timing of referral for intervention 6

Considerations for Treatment

• The patients who might benefit from tricuspid valve interventions are yet unknown, and the ideal time for these treatments is not well-defined 2
• Early identification of right heart failure and TR may be crucial for optimal management 2
• The choice of treatment option depends on various factors, including the severity of TR, the presence of coexisting conditions, and the patient's overall health status 3, 6, 5