What are the current indications and advances in therapies for tricuspid valve disease, particularly for patients with severe tricuspid regurgitation?

Current Indications and Advances in Tricuspid Valve Therapies

Surgery is indicated in patients with severe tricuspid regurgitation (TR) undergoing left-sided valve surgery, in symptomatic patients with severe isolated primary TR without severe right ventricular dysfunction, and in patients with severe tricuspid stenosis. 1

Indications for Tricuspid Valve Intervention

Primary (Organic) Tricuspid Regurgitation

• Class I (Strong) Indications:

  • Symptomatic patients with severe primary TR without severe right ventricular (RV) dysfunction 1
  • Patients with severe primary TR undergoing left-sided valve surgery 1

• Class IIa (Reasonable) Indications:

  • Moderate primary TR in patients undergoing left-sided valve surgery 1
  • Asymptomatic or mildly symptomatic patients with severe isolated primary TR and progressive RV dilatation or deterioration of RV function 2

• Class IIb (May Be Considered) Indications:

  • Asymptomatic or minimally symptomatic patients with severe primary TR and progressive degrees of moderate or greater RV dilation and/or systolic dysfunction 1

Secondary (Functional) Tricuspid Regurgitation

• Class I (Strong) Indications:

  • Severe secondary TR in patients undergoing left-sided valve surgery 1

• Class IIa (Reasonable) Indications:

  • Patients with mild or moderate TR at the time of left-sided valve surgery with dilated tricuspid annulus (≥40 mm or >21 mm/m²) 1

Tricuspid Stenosis

• Class I (Strong) Indications:
  • Symptomatic patients with severe tricuspid stenosis 1
  • Patients with severe tricuspid stenosis undergoing left-sided valve intervention 1

Surgical Approaches for Tricuspid Valve Disease

Tricuspid Valve Repair

• Preferred approach when feasible, especially for secondary TR 1
• Ring annuloplasty with prosthetic rings is the key technique for secondary TR 1
• Rigid or semi-rigid rings provide better long-term outcomes than flexible bands 2

Tricuspid Valve Replacement

• Should be considered when:
  • Tricuspid valve leaflets are significantly tethered 1
  • Annulus is severely dilated 1
  • Bioprosthetic valves are generally preferred over mechanical valves 2

Special Considerations

• In patients with transtricuspid pacemaker leads, surgical technique should be adapted to the patient's condition and surgeon's experience 1
• Reoperation for isolated tricuspid valve repair or replacement may be considered for persistent symptoms due to severe TR in patients who have undergone previous left-sided valve surgery 1

Advances in Tricuspid Valve Therapies

Transcatheter Tricuspid Valve Interventions

• Transcatheter tricuspid valve replacement has shown superiority to medical therapy alone in the TRISCEND II trial, primarily improving symptoms and quality of life 3

  • Win ratio favoring valve replacement was 2.02 (95% CI, 1.56 to 2.62; P<0.001)
  • Improvements in Kansas City Cardiomyopathy Questionnaire overall summary score (23.1% vs. 6.0%)
  • Improvements in NYHA functional class (10.2% vs. 0.8%)

• Complications of transcatheter approaches:

  • Severe bleeding (15.4% vs. 5.3% with medical therapy, P = 0.003) 3
  • Need for new permanent pacemakers (17.4% vs. 2.3%, P<0.001) 3

• Early feasibility studies of transcatheter annular reduction systems (e.g., Cardioband) have shown:

  • High procedural feasibility with no 30-day mortality
  • Significant reduction of functional TR
  • Clinically significant improvements in functional status and quality of life 4

Medical Management

• Loop diuretics are the cornerstone of initial therapy for symptomatic TR with congestion 2
• Aldosterone antagonists are particularly beneficial for patients with TR and systemic congestion 2
• Regular assessment of:
  • Blood pressure, electrolytes, and renal function
  • TR severity via echocardiography
  • Right ventricular function 2

Evaluation of Tricuspid Valve Disease

Echocardiographic Assessment

• Essential for evaluating:

  • Valve anatomy
  • Severity of regurgitation or stenosis
  • Right ventricular size and function
  • Presence of pulmonary hypertension
  • Tricuspid annular diameter 2

• Criteria for severe TR:

  • Central jet area >10.0 cm²
  • Vena contracta width >0.7 cm
  • Dense, triangular CW jet with early peak
  • Dilated RV/RA/IVC with decreased IVC respirophasic variation 1

Invasive Assessment

• Invasive hemodynamic assessment may be considered in symptomatic patients when clinical and noninvasive data are discordant 1

Contraindications and Pitfalls

Absolute Contraindications for Surgery

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

High-Risk Features for Surgery

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

Common Pitfalls

• Underestimating the impact of tricuspid valve disease can lead to poor outcomes 2
• Delaying surgery in symptomatic severe TR can lead to irreversible right ventricular damage 2
• Inadequate assessment of vegetation characteristics (when present) can influence surgical approach and risk of embolization 2

Future Directions

• Percutaneous tricuspid valve interventions are rapidly evolving and may become reliable options for high-risk patients 5
• Ongoing research is focusing on optimal patient selection and timing of intervention for isolated TR 6
• Development of stepwise algorithms for the management of symptomatic severe TR before transcatheter intervention is needed 6