What is the basis of management for severe tricuspid regurgitation and aortic regurgitation?

Management of Severe Tricuspid Regurgitation and Aortic Regurgitation

For severe tricuspid regurgitation, surgery with rigid or semi-rigid ring annuloplasty is the gold standard when performed concomitantly with left-sided valve surgery, while isolated severe TR requires surgery only in symptomatic patients without severe RV dysfunction or irreversible pulmonary hypertension; for severe aortic regurgitation, aortic valve replacement is indicated for all symptomatic patients regardless of LV function, and for asymptomatic patients when LVEF drops below 50-55% or LVESD exceeds 50 mm. 1

Severe Tricuspid Regurgitation Management

Diagnostic Assessment

• Transthoracic echocardiography with Doppler is the key diagnostic test to assess TR severity, valve morphology, RV size and function, and pulmonary artery pressures 1
• Severe TR is defined by EROA ≥0.40 cm² and tricuspid annular dilation >40 mm or >21 mm/m² in four-chamber view 1
• Right heart catheterization is reasonable when clinical and non-invasive data are discordant, particularly to assess pulmonary pressures and vascular resistance 1
• 3D transesophageal echocardiography and cardiac MRI provide detailed anatomical information and accurate RV volumetric analysis when needed 1

Medical Management

• Medical therapy is first-line for symptomatic TR with right-sided heart failure signs, but should not delay surgical or transcatheter referral when indicated 1
• Loop diuretics are recommended to relieve congestion in patients with right-sided heart failure 2
• Aldosterone antagonists may benefit TR-related volume overload 2
• Rhythm control strategies should be considered in patients with atrial fibrillation, as AF-induced annular remodeling is a major TR determinant 1

Surgical Indications and Techniques

When undergoing left-sided valve surgery:

• Surgery is indicated (Class I) for patients with severe primary or secondary TR 1
• Surgery is reasonable (Class IIa) for moderate TR with tricuspid annular dilatation ≥40 mm or >21 mm/m² 1
• Prophylactic TV surgery prevents TR progression and reduces mortality 1

For isolated severe TR:

• Surgery is indicated (Class I) in symptomatic patients with severe isolated primary TR without severe RV dysfunction 1
• Surgery is reasonable (Class II) for symptomatic patients with severe secondary TR in the absence of severe RV/LV dysfunction, severe pulmonary hypertension, or irreversible liver dysfunction 1
• Rigid or semi-rigid ring annuloplasty is the gold standard surgical technique, superior to flexible bands in preventing recurrent TR 1
• Valve replacement should be considered for patients with severe RV dysfunction, very large annuli, and significant leaflet tenting where repair outcomes are poor 1
• Bioprosthetic valves are usually preferred over mechanical valves 1

Conservative Management

• Conservative management is recommended for asymptomatic patients with severe primary TR but non-dilated RV 1
• Medical therapy alone is appropriate for symptomatic patients with severe secondary TR and either severe RV dysfunction or irreversible pulmonary hypertension, where surgery or transcatheter intervention is likely futile 1

Transcatheter Options

• Transcatheter tricuspid valve intervention may be considered for high-risk surgical patients at specialized centers with expertise 2, 3
• Evidence for transcatheter approaches is still emerging and not yet fully established 1, 4

Severe Aortic Regurgitation Management

Diagnostic Assessment

• Transthoracic echocardiography is the first-line diagnostic tool for AR diagnosis, severity quantification, and mechanism determination 1
• Severe AR is defined by EROA ≥0.30 cm², regurgitant volume ≥60 mL, regurgitant fraction ≥50%, and Doppler jet width ≥65% of LVOT 1
• Cardiac MRI provides accurate regurgitant volume and fraction when echocardiographic data are discordant or inadequate 1
• Transesophageal echocardiography offers superior assessment when TTE windows are suboptimal, particularly for eccentric jets 1

Medical Therapy

• For acute severe AR, medical therapy to reduce LV afterload should not delay urgent surgical intervention 1
• For chronic AR, there is limited role for medical therapy beyond managing symptoms and comorbidities 1

Surgical Indications

Symptomatic patients:

• AVR is indicated (Class I) for all symptomatic patients with severe AR regardless of LV systolic function, as surgical risk is not prohibitive 1

Asymptomatic patients with LV dysfunction:

• AVR is indicated (Class I) when LVEF <50% (JCS) or ≤55% (ACC/AHA) if no other cause explains the dysfunction 1
• AVR is indicated (Class I, ESC) when LVEF ≤50% or LVESD >50 mm or >25 mm/m² when surgical risk is low 1

Asymptomatic patients with preserved LV function:

• AVR is reasonable (Class IIa) when LVESD >50 mm or >45 mm (depending on guideline) 1
• AVR may be considered (Class IIb) with progressive decline in LVEF on serial studies or progressive LV dilatation into severe range (LVEDD >65 mm) 1

During other cardiac surgery:

• AVR is indicated (Class I) for patients with severe AR undergoing CABG, ascending aorta surgery, or other valve surgery 1
• AVR is reasonable (Class IIa, ACC/AHA) for moderate AR when undergoing other cardiac procedures 1

Surgical Techniques

• AVR with mechanical or bioprosthetic valve is the mainstay treatment 1
• When aortic root is dilated ≥45 mm, replacement of aortic sinuses and/or ascending aorta is reasonable at comprehensive valve centers 1
• Valve-sparing surgery may be considered in selected patients with bicuspid aortic valve at experienced centers when durable results are expected 1

Transcatheter Intervention

• TAVI should not be performed in patients with isolated severe AR who have indications for surgical AVR and are surgical candidates (Class III) 1
• TAVI may be considered at experienced centers for selected patients ineligible for surgical AVR 1

Critical Pitfalls and Caveats

For Tricuspid Regurgitation:

• Do not delay TR surgery until severe RV dysfunction develops, as outcomes are poor once irreversible RV dysfunction occurs 1
• Isolated TR surgery carries 8-10% operative mortality, so careful patient selection is essential 5
• When severe TR coexists with aortic stenosis, the presence of significant TR is associated with dismal outcomes regardless of treatment strategy, with 50% mortality within 3 months post-operatively 6, 7
• TV surgery is not recommended in patients with tricuspid annular dilatation but absent or only trace TR 1

For Aortic Regurgitation:

• Do not wait for symptoms to develop in patients with progressive LV dilatation or declining LVEF, as irreversible LV remodeling may occur 1
• Exact cut-off values for intervention in asymptomatic patients vary between guidelines (LVEF 50% vs 55%, LVESD 45 mm vs 50 mm), requiring clinical judgment 1
• Mixed valvular disease (AR with mitral regurgitation or stenosis) requires careful assessment to identify the predominant lesion, with sparse guideline recommendations 1

When Both Conditions Coexist:

• The combination of severe AS and severe TR represents a particularly high-risk scenario with >80% mortality in <4 years with conservative therapy 7
• Treatment decisions must prioritize the hemodynamically dominant lesion while considering RV function and surgical risk 6, 7

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