What is the treatment approach for moderate tricuspid regurgitation?

Treatment Approach for Moderate Tricuspid Regurgitation

For moderate tricuspid regurgitation, medical therapy with diuretics should be initiated as first-line treatment, with surgical intervention recommended when undergoing left-sided valve surgery, as per European Society of Cardiology guidelines. 1

Medical Management

Medical therapy forms the cornerstone of initial management for moderate TR:

• Loop diuretics (furosemide): Should be initiated or optimized to reduce volume overload 1
• Aldosterone antagonists (spironolactone): Particularly beneficial for patients with TR and systemic congestion, as they provide additional benefit for hepatic congestion and are less likely to worsen lymphedema compared to traditional diuretics 1
• Blood pressure management: Target blood pressure should be 120-129/70-79 mmHg if tolerated 1
• Heart failure therapy: Standard heart failure management including ACE inhibitors/ARBs, Beta blockers, and consideration of newer agents like SGLT2 inhibitors and sacubitril/valsartan for patients with concomitant heart failure 1, 2

Surgical Intervention Indications

The European Society of Cardiology provides clear guidance on when to consider surgical intervention for moderate TR:

• Class IIa recommendation: Moderate TR in patients undergoing left-sided valve surgery 1
• Class IIa recommendation: Mild or moderate TR with dilated annulus (≥40 mm or >21 mm/m²) in patients undergoing left-sided valve surgery 1

This represents a significant shift from historical approaches, as the traditional teaching that functional TR resolves on its own if the underlying disease is successfully treated has proven incorrect 3.

Surgical Techniques

When surgery is indicated, the following approaches are recommended:

• Ring annuloplasty with prosthetic rings: The key technique for secondary TR 1
• Valve replacement: Should be considered if the tricuspid valve is significantly deformed, there are advanced forms of leaflet tethering, or significant right ventricular dilatation is present 1
• Bioprosthetic valves: Preferred over mechanical valves for replacement 1

Monitoring and Follow-up

Regular monitoring is essential for patients with moderate TR:

• Echocardiography: Regular assessment of TR severity, right ventricular function, and progression 1
• Clinical assessment: Regular evaluation of symptoms, lymphedema status, blood pressure, electrolytes, and renal function 1
• Progression monitoring: Vigilance for signs of worsening TR or right ventricular dilatation/dysfunction that may warrant intervention 1

Emerging Transcatheter Options

For high-risk patients who are not surgical candidates, transcatheter options are emerging:

• Transcatheter tricuspid valve interventions: May be considered for patients deemed high risk for surgery, but only at specialized centers with expertise in TV disease 1, 4
• These approaches remain in development but show promise for the future, especially for patients with significant comorbidities 5, 6

Important Considerations and Pitfalls

• Avoid delaying intervention: Delaying surgery until severe right ventricular dysfunction develops significantly worsens outcomes 1
• Comprehensive assessment: Decision-making should be based not only on TR severity but also on annular size, right ventricular function, and degree of pulmonary hypertension 5
• Recognize poor prognostic factors: Severe TR is associated with poor prognosis independent of age, left and right ventricular function, and right ventricular size 1
• Contraindications: Be aware of contraindications for surgery including pre-operative TV tethering height >8 mm, irreversible RV dysfunction, advanced pulmonary hypertension, and irreversible liver cirrhosis 1

The management approach for moderate TR has evolved significantly, with increasing recognition of the importance of intervention, particularly at the time of left-sided heart valve surgery, to prevent progression to severe TR and its associated complications 1, 5.