What is the management approach for patients with mild tricuspid regurgitation?

Management of Mild Tricuspid Regurgitation

Mild tricuspid regurgitation (TR) generally does not require specific intervention and can be managed conservatively with regular monitoring and medical therapy when symptomatic. 1

Understanding Tricuspid Regurgitation

• TR is classified into primary (organic) and secondary (functional) types, with primary TR resulting from structural valve abnormalities and secondary TR resulting from annular dilation and/or leaflet tethering 1
• Mild TR is common and usually benign, while moderate or severe TR can lead to irreversible myocardial damage and adverse outcomes 2
• Functional TR is most often caused by right ventricular pressure and/or volume overload, commonly due to left-sided heart disease, pulmonary hypertension, or right ventricular intrinsic disease 3

Diagnostic Approach

• Transthoracic echocardiography (TTE) is the first-line imaging modality for assessing TR severity, right ventricular size and function 3, 1
• Additional imaging with 3D echocardiography, cardiovascular magnetic resonance (CMR), or right heart catheterization may be considered when clinical and non-invasive data are discordant 3
• Regular echocardiographic follow-up is essential to monitor for potential progression of TR severity and right ventricular function 1

Management Strategy for Mild TR

Medical Management

• For asymptomatic patients with mild TR and normal right ventricular function, observation with regular follow-up is appropriate 1, 4
• For patients with symptoms of right-sided heart failure (despite mild TR classification):
  • Diuretics, particularly loop diuretics, are recommended for symptom relief and management of volume overload 1, 4
  • Aldosterone antagonists may provide additional benefit in managing TR-related volume overload 1, 4
• For patients with atrial fibrillation contributing to TR, rhythm control strategies should be considered 1, 4

Surgical Considerations

• Isolated mild TR without other cardiac issues does not require surgical intervention 3
• In patients undergoing left-sided valve surgery:
  • Prophylactic tricuspid valve surgery is not indicated for mild TR without significant annular dilation 3
  • However, if tricuspid annular dilation is present (≥40 mm or >21 mm/m²) even with mild TR, prophylactic tricuspid valve repair may be considered during left-sided heart surgery (Class IIa recommendation by European guidelines, Class IIb by American and Japanese guidelines) 3

Follow-up Recommendations

• Regular clinical and echocardiographic follow-up to monitor for:
  • Progression of TR severity 1
  • Changes in right ventricular size and function 1
  • Development of pulmonary hypertension 3
• More frequent monitoring is warranted in patients with:
  • Left-sided heart disease 1
  • Pulmonary hypertension 3
  • History of atrial fibrillation 4
  • Progressive right ventricular enlargement 1

Important Considerations and Pitfalls

• The traditional belief that functional TR resolves on its own if the underlying disease is successfully treated has proven incorrect 2
• Untreated TR may progress over time, leading to right ventricular dysfunction and worse outcomes 5
• In patients with mild TR undergoing mitral valve surgery, 32% may show significant progression of TR if tricuspid annuloplasty is not performed concurrently 5
• Early intervention for TR during left-sided valve surgery may prevent subsequent progression of TR and right ventricular dysfunction 5

When to Consider Referral for Specialist Evaluation

• Development of symptoms despite medical therapy 3, 1
• Progression to moderate or severe TR 1
• Progressive right ventricular dilation or dysfunction 1
• Need for left-sided valve surgery in the presence of mild TR with annular dilation 3