What is the treatment approach for tricuspid regurgitation?

Treatment Approach for Tricuspid Regurgitation

Medical therapy is the first-line approach for patients with tricuspid regurgitation (TR) and right-sided heart failure symptoms, but should not delay referral for surgery or transcatheter therapy when indicated. 1, 2

Classification and Diagnosis

• TR is classified as primary (organic) when resulting from structural abnormalities of the tricuspid valve apparatus, or secondary (functional) when resulting from tricuspid annular dilation and/or leaflet tethering without primary valve pathology 2
• Echocardiography is the first-line imaging modality for assessing TR severity, right ventricular size and function 2
• Severe TR is characterized by central jet ≥50% of right atrium, dense continuous wave Doppler signal, vena contracta width ≥7 mm, PISA radius >9 mm, hepatic vein systolic flow reversal, EROA ≥0.4 cm², and regurgitant volume ≥45 mL/beat 2
• Additional imaging with 3D echocardiography, cardiovascular magnetic resonance, or right heart catheterization may be considered when clinical and non-invasive data are discordant 2

Medical Management

• Guideline-directed medical therapy (GDMT) for heart failure is the first-line treatment for both primary and secondary TR 2, 3
• Loop diuretics are recommended for symptom relief in patients with right-sided heart failure and congestion 2, 3
• Aldosterone antagonists may be beneficial in managing TR-related volume overload 2, 3
• Rhythm control strategies should be considered in patients with TR and atrial fibrillation, as AF-induced annular remodeling is a major determinant of secondary TR 1, 2
• Conservative management is recommended in:
  • Asymptomatic patients with severe primary TR but non-dilated right ventricle 1
  • Symptomatic patients with severe secondary TR and either severe RV dysfunction or irreversible pulmonary hypertension, where surgery or transcatheter intervention is likely futile 1

Surgical Management

• Surgery is recommended for:
  • Symptomatic patients with severe primary TR without severe right ventricular dysfunction (Class I, Level C) 2
  • Patients with severe TR undergoing left-sided valve surgery (Class I) 2
• The gold standard surgical treatment for secondary TR is rigid or semirigid ring annuloplasty, which is associated with reduced incidence of late, recurrent TR compared to flexible annuloplasty bands 1
• Valve replacement may be preferred over repair in patients with severe RV dysfunction, very large annuli, and significant leaflet tenting 1
• Prophylactic TV repair may be considered (Class IIb) during left-sided heart surgery if tricuspid annular dilation is present, even with mild TR, particularly in patients with persistent atrial fibrillation 1, 2
• TV surgery is not recommended in patients with tricuspid annular dilatation but absent or only trace TR 1

Transcatheter Interventions

• Transcatheter tricuspid valve interventions (TTVI) are emerging as options for high-risk patients who are poor surgical candidates 2, 4
• Patients with severe TR and RV dysfunction who are not surgical candidates may be considered for transcatheter treatment at specialized heart valve centers 3, 4
• Various transcatheter approaches are being developed, including edge-to-edge repair, annuloplasty devices, and valve replacement, though many remain investigational 4

Follow-up and Monitoring

• Regular echocardiographic assessment is essential to evaluate TR progression, right ventricular function, and response to therapy 2, 3
• Exercise stress echocardiography and cardiopulmonary exercise testing may be considered in asymptomatic patients for risk stratification 1, 2

Special Considerations

• Early intervention during left-sided valve surgery may prevent subsequent progression of TR and right ventricular dysfunction 2
• For atrial functional TR (related to atrial fibrillation), TV repair with annuloplasty may be considered in symptomatic or asymptomatic AF patients with progressive RV dysfunction and/or dilation despite GDMT (Class IIb) 1
• Referral to specialized heart valve centers with TTVI expertise should be considered for complex cases 1

Pitfalls and Caveats

• Delaying intervention until severe RV dysfunction develops may result in poor outcomes even with surgical or transcatheter intervention 5, 6
• Traditional teaching that functional TR resolves on its own if the underlying disease is successfully treated has proven incorrect 6
• Undertreatment of TR is common despite its association with increased morbidity and mortality 4, 6