What is the treatment for isolated tricuspid regurgitation?

Treatment for Isolated Tricuspid Regurgitation

The treatment for isolated tricuspid regurgitation should follow a stepwise approach, with medical therapy as first-line management and surgical or transcatheter interventions reserved for severe symptomatic cases or when right ventricular dysfunction begins to develop. 1, 2

Classification and Diagnosis

• Tricuspid regurgitation (TR) is classified as primary (organic) or secondary (functional), with primary TR resulting from structural valve abnormalities and secondary TR resulting from annular dilation and/or leaflet tethering without primary valve pathology 1
• Echocardiography is the first-line diagnostic tool to assess TR severity, with severe TR characterized by central jet ≥50% of right atrium, vena contracta width ≥7 mm, EROA ≥0.4 cm², and regurgitant volume ≥45 mL/beat 1
• Additional imaging with 3D echocardiography, cardiac MRI, or right heart catheterization may be necessary when clinical and non-invasive data are discordant 1

Medical Management

• Guideline-directed medical therapy is the first-line treatment for both primary and secondary isolated TR 1, 2
• Loop diuretics are recommended for symptom relief in patients with right-sided heart failure and congestion 1, 3
• Aldosterone antagonists may provide additional benefit in managing TR-related volume overload 1, 3
• Rhythm control strategies should be considered in patients with TR and atrial fibrillation, as atrial fibrillation is a common cause of isolated functional TR 1, 4

Surgical Management

• Surgery is recommended for symptomatic patients with severe primary TR without severe right ventricular dysfunction (Class I, Level C) 1
• Tricuspid valve repair with a prosthetic ring is preferred over replacement when technically feasible due to better post-operative outcomes 1
• Isolated tricuspid valve surgery should be considered before the onset of right ventricular dysfunction and end-organ damage in low-risk patients with symptomatic severe isolated TR 5
• Prophylactic tricuspid valve repair may be considered during left-sided heart surgery if tricuspid annular dilation is present (>40 mm or >21 mm/m²) 1, 3

Transcatheter Interventions

• Transcatheter tricuspid valve repair or replacement may be considered for high-risk patients with severe TR who are not candidates for surgery 2
• These percutaneous interventions are emerging therapies and may offer an alternative treatment for patients at increased surgical risk 5, 2

Special Considerations

• Isolated functional TR has historically been undertreated due to high mortality rates associated with isolated tricuspid valve surgery (8-10%) 5, 4
• Right ventricular function is a key factor in determining the indication for isolated tricuspid valve surgery and predicting outcomes 4
• Regular echocardiographic assessment is essential to evaluate TR progression, right ventricular function, and response to therapy 1
• The 5-year survival rate with severe TR and heart failure with reduced ejection fraction is only 34%, highlighting the importance of appropriate management 2

Pitfalls and Caveats

• Delaying intervention until advanced right ventricular dysfunction or end-organ damage occurs significantly worsens outcomes 5, 4
• Current guidelines do not fully address the management of isolated TR, creating uncertainty in clinical decision-making 5
• Significant recurrent regurgitation may occur after tricuspid valve repair 5
• Liver and renal function are important predictors of outcomes but specific cut-off values for improved surgical outcomes have not been well established 4