What is the initial management for a patient with tricuspid regurgitation?

Initial Management of Tricuspid Regurgitation

Start with guideline-directed medical therapy for heart failure as first-line treatment, using loop diuretics for symptom relief, while simultaneously assessing TR severity, etiology (primary vs. secondary), right ventricular function, and pulmonary pressures to determine if and when surgical or transcatheter intervention is needed. 1, 2

Immediate Medical Management

• Initiate loop diuretics (furosemide, torsemide, or bumetanide) as the cornerstone therapy to relieve systemic venous congestion, hepatic congestion, and peripheral edema 1, 3
• Add aldosterone antagonists (spironolactone or eplerenone) for additional volume management and to address TR-related volume overload 1, 3
• Implement guideline-directed medical therapy for heart failure with reduced ejection fraction if left ventricular dysfunction is present, including ACE inhibitors or ARBs, beta-blockers, and SGLT2 inhibitors 1, 3
• Consider rhythm control strategies if atrial fibrillation is present, as AF-induced annular remodeling is a major driver of secondary TR 2, 1

Medical therapy should not delay referral for surgery or transcatheter intervention when already indicated based on severity and symptoms 2, 1

Critical Diagnostic Assessment

Perform transthoracic echocardiography immediately to establish: 1, 2

TR Severity Classification:

• Severe TR criteria: central jet ≥50% of right atrium, vena contracta width ≥7 mm, PISA radius >9 mm, EROA ≥0.4 cm², regurgitant volume ≥45 mL/beat, hepatic vein systolic flow reversal 1, 2
• Dense continuous wave Doppler signal with triangular shape and dilated right heart chambers 1

Etiology Determination:

• Primary (organic) TR: structural valve abnormalities including leaflet damage, chordal rupture, vegetation, prolapse, or congenital abnormalities 1
• Secondary (functional) TR: tricuspid annular dilation and/or leaflet tethering without primary valve pathology, associated with RV dilation/dysfunction 1, 3

Right Ventricular Function Assessment:

• TAPSE (normal ≥17 mm, severe dysfunction <17 mm) 1
• RV free wall longitudinal strain from 2D speckle-tracking echocardiography 2, 1
• S' velocity (normal ≥10 cm/s) 1

Pulmonary Artery Pressure:

• Estimate PASP; pulmonary hypertension defined as >35-40 mmHg 1
• Severe irreversible pulmonary hypertension is a contraindication to surgery 2, 1

Tricuspid Annular Diameter:

• Measure annular size; ≥40 mm (or ≥21 mm/m²) indicates significant dilation 1

Algorithmic Decision-Making for Intervention

Scenario 1: Severe Primary TR

If symptomatic + severe primary TR + NO severe RV dysfunction:

• Proceed to surgery (Class I, Level C recommendation) 1, 2
• TV repair with rigid or semi-rigid ring annuloplasty is preferred over replacement 2, 1

If asymptomatic + severe primary TR + non-dilated RV:

• Continue medical management with close monitoring 2
• Serial echocardiography every 6-12 months 1

Scenario 2: Severe Secondary TR

If undergoing left-sided valve surgery + severe TR:

• Concomitant TV surgery is mandatory (Class I, Level B-NR) 1, 2
• This applies regardless of symptoms when severe TR is present 1

If undergoing left-sided valve surgery + mild-moderate TR + annular dilation ≥40 mm:

• Prophylactic TV repair should be considered (Class IIa) 1

If isolated severe secondary TR + symptomatic + NO severe RV dysfunction:

• Refer for surgical evaluation 1, 2
• Surgery is indicated if progressive RV dilation/dysfunction develops despite medical management 1

Scenario 3: Contraindications to Surgery

If severe irreversible RV dysfunction OR irreversible pulmonary hypertension:

• Surgery is futile and contraindicated 2, 1
• Continue aggressive medical management 2
• Refer to specialized heart valve center for transcatheter tricuspid valve intervention (TTVI) evaluation (Class IIb) 1, 2

If high surgical risk but NOT irreversible dysfunction:

• Refer to tertiary center with TTVI expertise 2, 1
• Transcatheter edge-to-edge repair or other TTVI options may be appropriate 4

Monitoring Parameters and Follow-Up

For patients on medical management, monitor:

• Progression of TR severity: advancement to vena contracta ≥7 mm, EROA ≥0.4 cm², central jet ≥50% RA triggers intervention consideration 1
• RV function deterioration: TAPSE declining to <17 mm or S' velocity <10 cm/s indicates worsening 1
• Development of pulmonary hypertension: PASP rising to >35-40 mmHg changes management 1
• Tricuspid annular diameter progression: reaching ≥40 mm triggers intervention if left-sided surgery becomes necessary 1
• Exercise stress echocardiography and cardiopulmonary exercise testing in asymptomatic patients for risk stratification 2, 1

Critical Pitfalls to Avoid

• Do NOT delay intervention until irreversible RV dysfunction develops - this is the most common error, as patients often respond initially to diuretics creating false reassurance 1, 5
• Do NOT perform TV surgery in patients with only tricuspid annular dilation but absent or trace TR 2
• Do NOT use flexible annuloplasty bands when rigid/semi-rigid rings are available - flexible bands have higher rates of recurrent TR 2
• Do NOT assume functional TR will resolve on its own if underlying disease is treated - this traditional teaching has proven incorrect 6
• Do NOT operate if severe irreversible RV dysfunction or irreversible pulmonary hypertension is present - surgery is futile in these cases 2, 1
• Avoid aggressive diuresis that precipitates hypotension and worsening renal function in low-output states 5

Special Populations

Atrial Fibrillation with Atrial Functional TR:

• TV repair with annuloplasty may be considered (Class IIb) in symptomatic or asymptomatic AF patients with progressive RV dysfunction/dilation despite medical therapy 2
• AF-induced annular remodeling is a major determinant of secondary TR requiring specific attention 2

Patients with Biventricular Dysfunction:

• Assess whether severe RV or LV dysfunction precludes surgical intervention 5
• For inoperable patients, transcatheter treatment at specialized centers may be considered 5
• Realistic pathway often involves aggressive medical management, specialized center evaluation for TTVI, and palliative care discussions if neither option is feasible 5