What is the best course of treatment for a patient with tricuspid regurgitation and mitral regurgitation, but normal echocardiogram results, including normal valve function and ejection fraction?

Management of Tricuspid and Mitral Regurgitation with Normal Echocardiographic Findings

Direct Answer

In patients with tricuspid and mitral regurgitation but normal valve morphology and ejection fraction on echocardiogram, the regurgitation is functional (secondary) rather than organic, and management should focus on identifying and treating the underlying cause—most commonly volume overload, atrial fibrillation, or subclinical left ventricular dysfunction—with aggressive medical optimization before any consideration of surgical intervention. 1, 2

Understanding the Mechanism

The presence of regurgitation with structurally normal valves indicates functional (secondary) regurgitation rather than primary valve pathology:

• Secondary mitral regurgitation results from left ventricular remodeling and annular dilatation despite normal valve leaflets, caused by altered ventricular geometry that prevents proper leaflet coaptation 1, 2

• Secondary tricuspid regurgitation occurs due to right ventricular pressure or volume overload leading to annular dilatation, not from intrinsic valve disease 2, 1

• Atrial fibrillation is present in 70-88% of patients with severe tricuspid regurgitation and causes progressive annular dilatation independent of ventricular dysfunction—this is a critical and often overlooked mechanism 1

• Trivial TR is frequently detected by echocardiography in normal subjects, and trace regurgitation through structurally normal valves can be detected in many healthy individuals 2

Initial Diagnostic Workup

Quantify the severity accurately using multiple parameters, as single measurements can be misleading:

For Mitral Regurgitation:

• Measure effective regurgitant orifice area (EROA ≥0.4 cm² = severe), regurgitant volume (≥60 mL = severe), and vena contracta width 1
• Assess left atrial and ventricular dimensions for chamber remodeling 1
• Common pitfall: Non-holosystolic or biphasic MR patterns often lead to overestimation of severity when using single-frame measurements like PISA 2

For Tricuspid Regurgitation:

• Measure vena contracta (≥7 mm = severe), EROA (≥0.4 cm² = severe), regurgitant volume (≥45 mL = severe) 2, 1
• Assess for hepatic vein systolic flow reversal and right heart chamber dilation 2, 1
• Measure tricuspid annular diameter (>35 mm or >21 mm/m² indicates significant dilatation) 2
• Evaluate tethering parameters: tenting area >1 cm² and coaptation distance >0.76 cm predict residual TR after repair 2, 3

Critical Additional Assessments:

• Screen for atrial fibrillation aggressively, as it is the dominant driver in most cases of functional TR 1
• Measure pulmonary artery systolic pressure to identify pulmonary hypertension as a contributing factor 2, 3
• Assess for volume overload states (renal dysfunction, heart failure) that can cause functional regurgitation 4
• Evaluate right ventricular function using TAPSE, fractional area change, and 3D volumes if available 2

Medical Management Strategy

Optimize guideline-directed medical therapy for the underlying condition before considering any intervention:

Primary Treatment Approach:

• Neurohormonal antagonists (ACE inhibitors/ARBs, beta-blockers, aldosterone antagonists) for left ventricular dysfunction 1
• Aggressive diuresis with loop diuretics for volume overload and congestion relief, adding aldosterone antagonists for enhanced volume management 1, 4
• Rhythm control strategies if atrial fibrillation is present—this is crucial as AF is the primary driver in most functional TR cases 1
• Consider cardiac resynchronization therapy if appropriate for underlying cardiomyopathy 1
• Coronary revascularization if ischemia is contributing to ventricular dysfunction 1

Evidence for Reversibility:

• In hemodialysis patients with volume overload, mitral regurgitation disappeared in 62% and tricuspid regurgitation in 67% after aggressive ultrafiltration, accompanied by decreased mitral annular diameter from 19.4±2 to 16.6±2 mm/m² 4
• After successful mitral valve repair, pulmonary hypertension and TR almost always diminish if the tricuspid valve anatomy is not grossly distorted 3

When to Consider Surgical Intervention

Surgery is NOT indicated for isolated functional regurgitation with normal valves unless specific criteria are met:

Mitral Regurgitation:

• Consider surgery only for severe secondary MR with persistent symptoms despite optimal medical therapy for at least 3-6 months 1
• Outcomes are less favorable than primary MR, so medical optimization must be exhausted first 1

Tricuspid Regurgitation:

• Isolated TR surgery has poor outcomes because right ventricular dysfunction has usually already occurred 5, 6
• Operative mortality for reoperation for TR is high with disappointing long-term results 6
• Class I indication: Severe TR in a patient already undergoing left-sided valve surgery 2
• Class IIa indication: Moderate TR with dilated annulus (>40 mm) in a patient undergoing left-sided valve surgery 2

Critical Timing Considerations:

• Mitral valve surgery should be performed before right ventricular dysfunction, severe TR, or advanced heart failure has occurred 5
• Tricuspid annuloplasty should be performed at the initial mitral valve surgery when annular diameter is ≥35 mm, as this provides more durable results than mitral repair alone 3, 5

Monitoring and Follow-Up

Serial surveillance is essential to detect progression:

• Perform echocardiography every 6-12 months to assess regurgitation severity, ventricular dimensions, and ventricular function 1
• Track tricuspid annular diameter progression, as 31% of patients with no preoperative TR develop moderate or greater TR by 5 years without intervention 7
• Monitor for right ventricular function deterioration using TAPSE and fractional area change 1, 2
• Common pitfall: Failing to assess tricuspid annular dimensions before any left-sided valve surgery leads to progressive TR postoperatively 3

Common Pitfalls to Avoid

• Do not assume all regurgitation requires intervention—trace and mild regurgitation through normal valves is common and often physiologic 2
• Do not underestimate volume overload as a reversible cause of functional regurgitation 4
• Do not ignore atrial fibrillation as a primary driver of progressive annular dilatation 1
• Do not use color Doppler jet size alone to grade severity—it is highly dependent on loading conditions and technical factors 2
• Do not delay addressing TR when performing mitral surgery if annular dilatation is present, as isolated TR surgery later has poor outcomes 5, 6