What are the implications of tricuspid regurgitation (TR) secondary to pulmonary hypertension (PH)?

From the Guidelines

Tricuspid regurgitation secondary to pulmonary hypertension should be managed with a focus on treating the underlying pulmonary hypertension and right ventricular dysfunction, with medical therapy as the first-line approach, and consideration of surgical or transcatheter intervention when indicated, as recommended by the most recent guidelines 1.

Management Approach

The management of tricuspid regurgitation secondary to pulmonary hypertension involves a multifaceted approach, including:

• Medical therapy to reduce pulmonary hypertension and alleviate right ventricular dysfunction
• Diuretics to manage volume overload and symptoms of right heart failure
• Oxygen therapy to maintain adequate oxygen saturation
• Consideration of surgical or transcatheter intervention for severe cases with refractory symptoms or significant right ventricular dysfunction

Medical Therapy

Medical therapy for tricuspid regurgitation secondary to pulmonary hypertension may include:

• Phosphodiesterase-5 inhibitors, such as sildenafil
• Endothelin receptor antagonists, such as bosentan
• Prostacyclin analogs, such as epoprostenol
• Diuretics, such as furosemide, to manage volume overload and symptoms of right heart failure

Surgical or Transcatheter Intervention

Surgical or transcatheter intervention may be considered for patients with severe tricuspid regurgitation and refractory symptoms or significant right ventricular dysfunction, as recommended by the 2022 AHA/ACC/HFSA guideline for the management of heart failure 1.

Underlying Pathophysiology

The underlying pathophysiology of tricuspid regurgitation secondary to pulmonary hypertension involves right ventricular pressure overload leading to ventricular dilation, which distorts the tricuspid valve apparatus and prevents leaflet coaptation, creating a vicious cycle of regurgitation and worsening ventricular function 1.

Key Considerations

Key considerations in the management of tricuspid regurgitation secondary to pulmonary hypertension include:

• Early referral to a multidisciplinary team for consideration of intervention
• Close monitoring of right ventricular function and pulmonary hypertension
• Aggressive management of volume overload and symptoms of right heart failure
• Consideration of surgical or transcatheter intervention for severe cases with refractory symptoms or significant right ventricular dysfunction, as recommended by the most recent guidelines 1.

From the Research

Tricuspid Regurgitation Secondary to Pulmonary Hypertension

• Tricuspid regurgitation (TR) is a common finding in patients with pulmonary arterial hypertension (PAH), with significant TR affecting about 23% of patients with PAH 2.
• The simultaneous presence of PAH and secondary tricuspid regurgitation (STR) portends particularly poor outcomes, with an increased risk of cardiovascular events and mortality 3, 4.
• Functional TR, the most common form of TR, is caused by cardiomyopathies, LV valve disease, or pulmonary disease, including PAH 5, 6.

Pathophysiology and Mechanisms

• Anatomic and functional alterations in the right ventricle rather than the tricuspid valve are implicated in developing significant STR in PAH 3.
• Right ventricular remodeling and dilation due to PAH can lead to distortion of the valve apparatus, resulting in secondary TR 4.
• The severity of TR correlates with PAH severity, with severe TR associated with greater right atrial dilatation, right ventricular dilatation, and higher levels of B-type natriuretic peptide 2.

Prognostic Significance

• Severe TR is a significant predictor of long-term mortality rate in PAH, with a strong association with greater 5-year mortality risk after adjustment for age, sex, functional class, and other factors 2.
• The presence and severity of TR are associated with patient characteristics, pulmonary artery hemodynamics, and outcome, with severe TR correlated with shorter mean 6-minute walk distances and higher levels of B-type natriuretic peptide 2.

Management and Treatment

• Management of TR includes diuretics, ACE inhibitors, and aldosterone antagonists, with surgical annuloplasty or valve replacement considered in patients with progressive RV dilatation without severe LV dysfunction and pulmonary hypertension 5.
• Transcatheter repair/replacement is an emerging therapy for high-risk patients with TR who would otherwise have a dismal clinical prognosis 5, 6.
• The treatment of TR in patients undergoing left-sided cardiac surgery is well established, but isolated surgical repair of TR is rarely performed due to prohibitive risk and higher perioperative mortality 6, 4.