What are the management options for tricuspid regurgitation?

Management of Tricuspid Regurgitation

Medical therapy with diuretics and guideline-directed heart failure management is the first-line approach for symptomatic TR, but surgical intervention with rigid or semi-rigid ring annuloplasty should be performed for severe primary TR in symptomatic patients without severe RV dysfunction, and concomitantly during any left-sided valve surgery when severe TR is present. 1, 2

Initial Assessment and Classification

Classify TR into primary (organic) versus secondary (functional) types, as this fundamentally determines management strategy 1:

• Primary TR results from structural valve abnormalities including leaflet damage, chordal rupture, vegetation, or congenital abnormalities 1
• Secondary TR results from tricuspid annular dilation and/or leaflet tethering without primary valve pathology, most commonly from RV dilation and dysfunction 1

Perform transthoracic echocardiography to assess TR severity using these criteria for severe TR 1, 2:

• Central jet ≥50% of right atrium 1
• Vena contracta width ≥7 mm 1
• EROA ≥0.4 cm² 1, 2
• Regurgitant volume ≥45 mL/beat 1
• Tricuspid annular dilation >40 mm or >21 mm/m² 2
• Hepatic vein systolic flow reversal 1

Medical Management Strategy

Initiate guideline-directed medical therapy for heart failure with reduced ejection fraction as first-line treatment for both primary and secondary isolated TR 1, 3:

• Loop diuretics for symptom relief in right-sided heart failure and congestion 1, 3
• Aldosterone antagonists for TR-related volume overload 1, 3
• Rhythm control strategies in patients with concurrent atrial fibrillation, as AF-induced annular remodeling is a major determinant of secondary TR 4, 3

Medical therapy should not delay surgical or transcatheter referral when intervention is already indicated 4, 2

Surgical Intervention Indications

Class I Recommendations (Strongest Evidence)

Operate on symptomatic patients with severe primary TR without severe RV dysfunction 1:

• This is a Class I, Level C recommendation from both ACC/AHA and ESC 1
• Do not operate if severe irreversible RV dysfunction or irreversible pulmonary hypertension is present, as surgery is likely futile 4, 2

Perform TV surgery for patients with severe TR undergoing left-sided valve surgery 1:

• This is Class I, Level B-NR (ACC/AHA) and Class I, Level C (ESC) 1
• This applies regardless of symptoms when severe TR is present 1

Class IIa Recommendations (Moderate Evidence)

Consider prophylactic TV repair during left-sided heart surgery if tricuspid annular dilation ≥40 mm or ≥21 mm/m² is present, even with mild-moderate TR 1:

• European guidelines give this Class IIa recommendation 1
• American and Japanese guidelines give Class IIb 1
• Early intervention may prevent subsequent progression of TR and RV dysfunction 1

Consider TV repair with annuloplasty in symptomatic or asymptomatic AF patients with progressive RV dysfunction and/or dilation despite guideline-directed medical therapy 4:

• This addresses atrial functional TR specifically 4
• Class IIb recommendation for prophylactic TV annuloplasty in patients with mild TR and persistent AF when undergoing other procedures 4

Surgical Technique Selection

Use rigid or semi-rigid ring annuloplasty as the gold standard surgical technique 4, 2:

• Rigid/semi-rigid rings are superior to flexible annuloplasty bands in preventing late recurrent TR 4, 2
• TV repair is preferable to replacement when feasible due to better post-operative outcomes 1

Consider valve replacement instead of repair in patients with 4:

• Severe RV dysfunction 4
• Very large annuli 4
• Significant leaflet tenting 4

Monitoring and Follow-Up Parameters

Perform regular echocardiographic assessment to evaluate 1:

• TR progression 1
• RV function (TAPSE <17 mm or S' velocity <10 cm/s indicates worsening) 1
• Development of pulmonary hypertension (PASP >35-40 mmHg changes management) 1

Use RV free wall longitudinal strain from 2D speckle-tracking echocardiography as endorsed by Japanese and European guidelines for more sensitive RV function assessment 4

Consider exercise stress echocardiography and cardiopulmonary exercise testing in asymptomatic patients for risk stratification and exercise capacity assessment 4, 1

Transcatheter Tricuspid Valve Intervention (TTVI)

TTVI may be considered for high-risk surgical patients with severe TR 5, 6:

• This technology is still in early development with only hundreds of patients treated 6
• Referral to tertiary heart valve centers with TTVI expertise is recommended 4
• The role of TTVI in high-risk patients needs further determination 6

Critical Pitfalls to Avoid

Do not delay surgery for isolated severe TR until severe RV dysfunction develops 7:

• Isolated TR significantly worsens survival when left untreated 7
• Stand-alone surgery for isolated TR carries 8-10% operative mortality, but this increases substantially with advanced RV dysfunction 7
• Operate on low-risk patients with symptomatic severe isolated TR prior to onset of RV dysfunction and end-organ damage 7

Do not perform TV surgery in patients with tricuspid annular dilation but absent or only trace TR 4

Do not use flexible bands when rigid/semi-rigid rings are available, as they have higher rates of recurrent TR 4, 2