What are the guidelines for intervention in patients with severe tricuspid regurgitation (TR)?

Guidelines for Tricuspid Valve Intervention and Management of Tricuspid Regurgitation

Surgical intervention is strongly recommended for patients with severe tricuspid regurgitation (TR) who are undergoing left-sided valve surgery, and should be considered in symptomatic patients with isolated severe primary TR without severe right ventricular dysfunction. 1

Classification of Tricuspid Regurgitation

Primary (Organic) TR

• Results from structural abnormalities of the tricuspid valve apparatus including leaflet damage, chordal rupture, vegetation, or congenital abnormalities 1
• Less common than secondary TR 2

Secondary (Functional) TR

• Results from tricuspid annular dilation and/or leaflet tethering without primary valve pathology 1
• Most commonly associated with:
  • Left-sided heart disease causing pulmonary hypertension 2
  • Right ventricular dilation and dysfunction 1
  • Atrial fibrillation causing annular remodeling 1
  • Pulmonary hypertension from any cause 1, 2

Diagnostic Criteria for Severe TR

Echocardiographic criteria for severe TR include:

• Central jet ≥50% of right atrium 1
• Dense continuous wave Doppler signal with triangular shape 1
• Vena contracta width ≥7 mm 1
• PISA radius >9 mm 1
• Hepatic vein systolic flow reversal 1
• EROA ≥0.4 cm² 1
• Regurgitant volume ≥45 mL/beat 1
• Dilated right heart chambers 1

Indications for Intervention in Severe TR

Symptomatic Patients with Isolated Primary TR

• Surgery is recommended for symptomatic patients with severe primary TR without severe RV dysfunction (Class I, Level C - ESC) 1
• Surgery can be beneficial to reduce symptoms and recurrent hospitalizations in right-sided heart failure with severe isolated primary TR (Class IIa, Level B-NR - ACC/AHA) 1

Asymptomatic Patients with Isolated Primary TR

• Surgery should be considered in asymptomatic or mildly symptomatic patients with isolated severe primary TR and RV dilation who are appropriate for surgery (Class IIa, Level C - ESC) 1
• Surgery may be considered in asymptomatic patients with isolated severe primary TR and progressive RV dilation or systolic dysfunction (Class IIb, Level C - ACC/AHA) 1

Patients with Secondary TR

• Surgery should be considered in patients with severe secondary TR (with or without previous left-sided surgery) who are symptomatic or have RV dilation, in the absence of severe RV/LV dysfunction and severe pulmonary vascular disease/hypertension (Class IIa, Level B - ESC) 1
• Surgery can be beneficial in refractory right-sided heart failure and severe isolated secondary TR attributable to annular dilation (in the absence of pulmonary hypertension or left-sided disease) to reduce symptoms and recurrent hospitalizations (Class IIa, Level B-NR - ACC/AHA) 1
• In asymptomatic patients with severe TR due to atrial fibrillation, progressive RV dysfunction, and/or dilation despite guideline-directed medical therapy, TV repair may be considered (Class IIb, Level C - ESC) 1

Concomitant TV Surgery During Left-Sided Valve Surgery

• TV surgery is strongly recommended for patients with severe TR undergoing left-sided valve surgery (Class I, Level B-NR - ACC/AHA; Class I, Level C - ESC) 1
• TV repair may be considered for patients with mild TR and tricuspid annular dilation (>40 mm or >21 mm/m²) or with mild TR and persistent atrial fibrillation when undergoing left-sided valve surgery (Class IIb, Level C) 1

Reoperation for Isolated TR

• Reoperation with isolated TV surgery may be considered in patients with refractory right-sided heart failure, severe TR, and previous left-sided valve surgery, in the absence of severe pulmonary hypertension or severe RV systolic dysfunction (Class IIb, Level B-NR - ACC/AHA) 1

Surgical Approach

• TV repair with a prosthetic ring is the first-line surgical approach when intervention is indicated 1
• TV repair is preferable to replacement when feasible due to better post-operative outcomes 1
• Valve replacement may be considered in cases with severe leaflet tethering, very large annuli, or significant leaflet damage 1

Transcatheter Interventions

• Transcatheter treatment of symptomatic secondary severe TR may be considered in inoperable patients at a heart valve center with expertise in the treatment of TV disease (Class IIb, Level C - ESC) 1
• Emerging transcatheter options include edge-to-edge repair, annuloplasty, and caval valve implantation, which offer less-invasive alternatives for high-risk patients 3

Medical Management

• Guideline-directed medical therapy for heart failure with reduced ejection fraction is the first-line treatment in isolated primary and secondary TR 1
• Diuretics (particularly loop diuretics) are recommended for symptom relief in patients with right-sided heart failure and congestion 1
• Aldosterone antagonists may be beneficial in managing TR-related volume overload 1
• Rhythm control strategies should be considered in patients with TR and atrial fibrillation 1

Common Pitfalls and Caveats

• Delaying intervention until severe RV dysfunction or irreversible pulmonary hypertension develops significantly worsens outcomes 4, 5
• The traditional view that functional TR generally resolves with surgical correction of primary left-sided lesions is no longer supported by evidence 6
• Isolated TR surgery carries higher operative risk (8-10% mortality) compared to other valve surgeries, emphasizing the importance of proper patient selection and timing 4
• Recurrent TR after repair is common, particularly in cases with severe annular dilation or significant leaflet tethering 6
• TV surgery is generally not recommended in patients with tricuspid annular dilation but absent or only trace TR 1

Follow-up and Monitoring

• Regular echocardiographic assessment is essential to evaluate TR progression, RV function, and response to therapy 1
• Exercise stress echocardiography and cardiopulmonary exercise testing may be considered in asymptomatic patients to assess exercise capacity and risk stratification 1