What is the management of severe tricuspid regurgitation?

Management of Severe Tricuspid Regurgitation

For severe tricuspid regurgitation, surgery with rigid or semi-rigid ring annuloplasty is recommended when performed concomitantly with left-sided valve surgery (Class I), while isolated severe TR requires surgery only in symptomatic patients without severe right ventricular dysfunction or irreversible pulmonary hypertension. 1, 2

Initial Diagnostic Assessment

Confirm severity using transthoracic echocardiography with specific quantitative criteria: 1, 2

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

Assess right ventricular function and pulmonary pressures to determine surgical candidacy: 1, 3

• TAPSE <17 mm indicates severe RV dysfunction (contraindication to surgery)
• RV free wall longitudinal strain provides more sensitive assessment
• Pulmonary artery systolic pressure >35-40 mmHg indicates pulmonary hypertension

Medical Management Strategy

Initiate guideline-directed medical therapy for heart failure as first-line treatment, but do not delay surgical referral when intervention is already indicated: 1, 3

Loop diuretics are the cornerstone for relieving systemic and hepatic congestion: 4, 1, 3

• Titrate aggressively to relieve symptoms
• Monitor for worsening low-flow syndrome, particularly in biventricular dysfunction
• Avoid excessive diuresis causing hypotension and renal dysfunction

Add aldosterone antagonists for additional volume management in TR-related overload. 1, 3

Implement rhythm control strategies in patients with concurrent atrial fibrillation, as AF-induced annular remodeling is a major determinant of secondary TR. 1

Surgical Intervention Indications

Class I Recommendations (Must Operate)

Operate on patients with severe TR undergoing left-sided valve surgery, regardless of symptoms: 4, 1

• This is the most common scenario for tricuspid valve surgery
• Concomitant repair prevents subsequent TR progression

Operate on symptomatic patients with severe primary (organic) TR without severe RV dysfunction: 1, 2

• Primary TR results from structural valve abnormalities (leaflet damage, chordal rupture, vegetation, congenital abnormalities)
• Surgery must occur before irreversible RV dysfunction develops

Operate on patients with isolated, symptomatic severe tricuspid stenosis: 4

Class IIa Recommendation (Should Consider)

Consider concomitant tricuspid valve repair during left-sided valve surgery when tricuspid annular dilation ≥40 mm or ≥21 mm/m² is present, even without severe TR: 1

• This prophylactic approach prevents subsequent TR progression
• Early intervention may prevent right ventricular dysfunction

Absolute Contraindications to Surgery

Do not operate if any of the following are present: 1, 2, 3

• Severe irreversible RV dysfunction
• Severe irreversible pulmonary hypertension
• Severe left ventricular dysfunction (in isolated TR cases)
• Surgery is likely futile in these scenarios

Surgical Technique Selection

Rigid or semi-rigid ring annuloplasty is the gold standard surgical technique and superior to flexible annuloplasty bands in preventing late recurrent TR: 1, 2

• Flexible bands have higher rates of recurrent TR and should not be used when rigid/semi-rigid rings are available
• Valve repair is preferable to replacement when feasible due to better postoperative outcomes

Consider valve replacement instead of repair in specific circumstances: 1

• Severe RV dysfunction
• Very large annuli
• Significant leaflet tenting
• Valve destruction or multiple levels of pathological involvement

Transcatheter Tricuspid Valve Intervention (TTVI)

Refer high-risk surgical patients with severe TR to tertiary heart valve centers with TTVI expertise: 1, 3

• TTVI may be considered for inoperable patients with severe TR and biventricular dysfunction (Class IIb)
• Multiple transcatheter devices are emerging with promising early results
• Randomized trial data is currently lacking

Bicaval valve implantation (CAVI) represents a technically simpler alternative for patients unsuitable for other transcatheter devices due to anatomical or imaging constraints. 5

Monitoring Parameters for Conservative Management

For patients not meeting surgical criteria, monitor the following parameters at regular intervals: 1

• Tricuspid annular diameter: Progression to ≥40 mm (or ≥21 mm/m²) triggers consideration for intervention if left-sided surgery becomes necessary
• RV function: Deterioration in TAPSE (<17 mm) or S' velocity (<10 cm/s) indicates worsening
• Pulmonary artery pressure: Development of pulmonary hypertension (PASP >35-40 mmHg) changes management
• TR severity progression: Advancement to severe criteria necessitates intervention

Use exercise stress echocardiography and cardiopulmonary exercise testing in asymptomatic patients for risk stratification and exercise capacity assessment. 1

Critical Pitfalls to Avoid

Do not perform TV surgery in patients with tricuspid annular dilation but absent or only trace TR. 1

Do not delay intervention until irreversible RV dysfunction develops—patients often respond well to diuretic therapy initially, creating false reassurance. 3

Recognize that severe TR is associated with significant morbidity and mortality even with normal left heart function, and conservative management provides only symptomatic relief without altering disease progression. 6, 7

Avoid using flexible bands when rigid/semi-rigid rings are available, as they have demonstrably higher rates of recurrent TR. 1

For patients with biventricular dysfunction and low-pressure severe TR, the realistic management pathway involves aggressive medical management, evaluation at a specialized heart valve center for potential transcatheter intervention, and palliative care discussions if neither surgical nor transcatheter options are feasible. 3