What is the treatment for mitral and tricuspid regurgitation?

Treatment of Mitral and Tricuspid Regurgitation

The optimal treatment for mitral and tricuspid regurgitation includes guideline-directed medical therapy as first-line management, with surgical or transcatheter interventions indicated for severe regurgitation based on symptoms, ventricular function, and valve anatomy.

Medical Management

For Both Mitral and Tricuspid Regurgitation

• Diuretics (loop diuretics and aldosterone antagonists) to reduce congestion and volume overload 1
• Standard heart failure management including:
  • ACE inhibitors/ARBs
  • Beta blockers
  • Mineralocorticoid receptor antagonists
  • Consider newer agents like SGLT2 inhibitors and sacubitril/valsartan for patients with heart failure 2
• Target blood pressure: 120-129/70-79 mmHg if tolerated 1
• Regular monitoring of:
  • Blood pressure
  • Electrolytes and renal function
  • Regurgitation severity via echocardiography
  • Ventricular function 1

Surgical Management

Mitral Regurgitation (MR)

Primary MR Indications for Surgery:

• Symptomatic patients with severe MR (Class I)
• Asymptomatic patients with severe MR and:
  • LV dysfunction (LVEF ≤60%) (Class I)
  • LV dilatation (LVESD ≥40mm) (Class I)
  • New-onset atrial fibrillation or pulmonary hypertension (Class IIa) 2

Secondary MR Indications for Surgery:

• Severe MR in patients undergoing CABG (Class I)
• Symptomatic patients with severe MR despite optimal heart failure GDMT, including CRT when indicated (Class IIa) 2

Surgical Approach:

• Mitral valve repair is preferred over replacement when technically feasible
• Minimally invasive approaches should be considered in appropriate candidates 2

Tricuspid Regurgitation (TR)

Indications for Tricuspid Surgery:

• Severe TR in patients undergoing left-sided valve surgery (Class I) 2, 1
• Symptomatic patients with severe isolated primary TR without severe RV dysfunction (Class I) 2, 1
• Moderate TR in patients undergoing left-sided valve surgery (Class IIa) 2, 1
• Mild or moderate TR with dilated annulus (≥40 mm or >21 mm/m²) in patients undergoing left-sided valve surgery (Class IIa) 2
• Asymptomatic or mildly symptomatic patients with severe isolated primary TR and progressive RV dilatation or deterioration of RV function (Class IIa) 2, 1

Surgical Approach:

• Tricuspid valve repair with annuloplasty ring is preferred over replacement when feasible 1
• Ring annuloplasty is the key technique for secondary TR 1
• Valve replacement should be considered if the tricuspid valve is significantly deformed or there are advanced forms of leaflet tethering 1
• Bioprosthetic valves are preferred over mechanical valves for tricuspid replacement 1

Combined Mitral and Tricuspid Valve Disease

Management Approach:

1. Assess predominant lesion: When either stenosis or regurgitation is predominant, management follows recommendations for the predominant valve disease 2
2. Concomitant repair: Recent evidence strongly supports concomitant tricuspid repair during mitral valve surgery when moderate TR or annular dilatation is present 3
3. Benefits of combined approach: Concomitant tricuspid annuloplasty during mitral valve surgery significantly reduces the risk of TR progression (0.6% vs 6.1%) 3

Important Considerations:

• Without tricuspid repair, 31% of patients with no preoperative TR develop moderate or greater TR by 5 years, as do 62% with moderate TR 4
• Delaying tricuspid intervention until severe RV dysfunction develops significantly worsens outcomes 1
• Concomitant transcatheter mitral and tricuspid valve repair may be associated with improved survival compared to isolated mitral repair in high-risk patients with both conditions 5

Transcatheter Interventions

For Mitral Regurgitation:

• Transcatheter edge-to-edge repair (TEER) may be considered for:
  • Symptomatic patients with primary MR at high/prohibitive surgical risk with favorable anatomy 2
  • Symptomatic patients with secondary MR despite GDMT with LVEF >30% and no indication for coronary revascularization 2

For Tricuspid Regurgitation:

• Transcatheter tricuspid valve interventions may be considered for patients deemed high risk for surgery, at specialized centers with expertise in TV disease 1

Monitoring and Follow-up

• Asymptomatic severe MR requires follow-up every 6-12 months 2
• Regular echocardiographic surveillance is essential for post-intervention monitoring 1
• Monitor for progression of regurgitation and ventricular function 1
• Evaluate for need for permanent pacemaker (higher risk with tricuspid repair, 14.1% vs 2.5%) 3

Pitfalls and Caveats

1. Delayed intervention: Waiting until severe RV dysfunction develops before addressing TR leads to poorer outcomes 1
2. Underestimating TR: Functional TR is often underestimated and can progress after isolated mitral valve surgery 4
3. Pacemaker risk: Tricuspid repair carries a higher risk of permanent pacemaker implantation 3
4. Contraindications: Severe RV dysfunction with very large annuli and significant leaflet tethering, irreversible liver cirrhosis, and advanced pulmonary hypertension are contraindications for tricuspid surgery 1
5. Recurrent TR: Even with tricuspid repair, TR can progressively return, similar to mitral valve repair 4

By following these guidelines and considering both medical and surgical/interventional approaches, optimal management of mitral and tricuspid regurgitation can be achieved to improve morbidity, mortality, and quality of life.