What is the management approach for tricuspid regurgitation (TR)?

Management of Tricuspid Regurgitation

For symptomatic patients with severe primary TR and preserved right ventricular function, surgery is strongly recommended (Class I), while medical therapy with guideline-directed heart failure medications and aggressive diuretic management forms the foundation for all TR patients, with transcatheter intervention emerging as an alternative for high-risk surgical candidates. 1

Classification and Severity Assessment

TR must first be classified as primary (organic valve pathology including leaflet damage, chordal rupture, vegetation, or congenital abnormalities) versus secondary (functional TR from annular dilation and/or leaflet tethering without primary valve disease, typically from RV dilation). 1

Echocardiographic criteria defining severe TR include: 1

• 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
• Dilated right heart chambers

Transthoracic echocardiography is the first-line imaging modality, with 3D echocardiography, cardiovascular magnetic resonance, or right heart catheterization reserved for discordant clinical and non-invasive data. 1

Medical Management Strategy

Guideline-directed medical therapy for heart failure with reduced ejection fraction is the first-line treatment for both isolated primary and secondary TR, and should not delay surgical or transcatheter referral when intervention is already indicated. 1

Pharmacologic Approach

• Loop diuretics are the cornerstone for relieving systemic and hepatic congestion, requiring aggressive titration to achieve symptom relief 1, 2
• Aldosterone antagonists provide additive benefit for TR-related volume overload, particularly when hepatic congestion promotes secondary hyperaldosteronism 1, 2
• Rhythm control strategies should be implemented in patients with concurrent atrial fibrillation, as AF-induced annular remodeling is a major determinant of secondary TR 1

Medical therapy includes ACE inhibitors as part of standard heart failure management. 3

Surgical Intervention: Indications and Timing

Class I Indications (Strongest Recommendations)

Surgery is strongly recommended for: 1

• Symptomatic patients with severe primary TR without severe RV dysfunction (ACC/AHA Class I, Level C; ESC Class I, Level C)
• All patients with severe TR undergoing left-sided valve surgery, regardless of symptoms (ACC/AHA Class I, Level B-NR; ESC Class I, Level C) 1, 2

This concomitant repair prevents subsequent TR progression and is critical because reoperation for isolated TR after previous left-sided valve surgery carries 10-25% perioperative mortality. 1, 2

Class IIa Indication

Prophylactic tricuspid valve repair should be considered during left-sided heart surgery if tricuspid annular dilation ≥40 mm or ≥21 mm/m² is present, even without severe TR. 1

Absolute Contraindications to Surgery

Surgery should not be performed in patients with: 1, 2

• Severe irreversible RV dysfunction
• Severe and uncorrectable pulmonary hypertension
• Irreversible liver dysfunction or advanced cirrhosis from chronic hepatic congestion

Surgical Technique Selection

TV repair with a rigid or semi-rigid prosthetic ring is the first-line surgical approach when intervention is indicated, as these are superior to flexible annuloplasty bands in preventing late recurrent TR. 1, 2

Valve replacement instead of repair should be considered in specific circumstances: 1, 2

• Severe RV dysfunction
• Very large annuli
• Significant leaflet tenting
• Valve destruction

Transcatheter Tricuspid Valve Intervention (TTVI)

Referral to tertiary heart valve centers with TTVI expertise is recommended for high-risk surgical patients with severe TR (ESC Class IIb, Level C). 1, 2

Recent data from the TRISCEND II trial demonstrated that transcatheter tricuspid-valve replacement was superior to medical therapy alone for severe symptomatic TR, with a win ratio of 2.02 (95% CI, 1.56 to 2.62; P<0.001), driven primarily by improvements in symptoms and quality of life. 4 However, severe bleeding occurred in 15.4% versus 5.3% in medical therapy, and new permanent pacemakers were required in 17.4% versus 2.3%. 4

TTVI may be particularly beneficial for patients with LVEF <40%, dilated annuli, and impaired RV function who are at high surgical risk. 3

Monitoring Parameters and Follow-Up

Serial transthoracic echocardiography is essential to monitor: 1, 2

• TR severity progression (vena contracta approaching ≥7 mm, EROA approaching ≥0.4 cm²)
• Tricuspid annular diameter (threshold ≥40 mm or ≥21 mm/m²)
• RV function deterioration (TAPSE <17 mm, S' velocity <10 cm/s)
• Pulmonary artery pressure development (PASP >35-40 mmHg)

RV free wall longitudinal strain from 2D speckle-tracking echocardiography provides more sensitive RV function assessment than TAPSE alone. 1

Exercise stress echocardiography and cardiopulmonary exercise testing may be considered in asymptomatic patients for risk stratification and exercise capacity assessment. 1

Critical Pitfalls to Avoid

The most devastating error is delaying surgical evaluation until irreversible hepatic dysfunction or severe RV dysfunction develops—patients often respond initially to diuretic therapy, creating false reassurance. 2 The five-year survival with severe TR and heart failure with reduced ejection fraction is only 34%. 3

Do not perform TV surgery in patients with tricuspid annular dilation but absent or only trace TR. 1, 2

Do not use flexible bands when rigid/semi-rigid rings are available, as flexible bands have higher rates of recurrent TR. 1, 2

Avoid aggressive diuresis that precipitates hypotension and worsening renal function in low-output states. 2

Special Populations

Chronic Liver Disease

In patients with chronic liver disease and severe TR, aggressive medical management should be initiated, but surgical intervention must be considered early in symptomatic patients with preserved RV function before irreversible hepatic dysfunction develops. 2 Irreversible liver dysfunction from chronic hepatic congestion is an absolute contraindication to tricuspid valve surgery. 1, 2

Atrial Fibrillation

Rhythm control is particularly important as AF-induced annular remodeling is a major determinant of secondary TR and can lead to isolated TR even in the absence of other cardiac abnormalities. 1, 5