What is the management plan for a patient with severe left ventricular dysfunction, significant tricuspid regurgitation, and elevated pulmonary artery pressures?

Management of Severe Biventricular Dysfunction with Significant Tricuspid Regurgitation and Pulmonary Hypertension

This patient requires aggressive guideline-directed medical therapy for heart failure with reduced ejection fraction as the immediate priority, with diuretic optimization for right-sided congestion, while deferring surgical intervention given the severely reduced biventricular function (LVEF 30-35%, RV dysfunction with TAPSE 1.6 cm) which portends prohibitively high surgical risk. 1, 2

Immediate Medical Management

Heart Failure Optimization

• Initiate or optimize guideline-directed medical therapy (GDMT) for heart failure with reduced ejection fraction, including ACE inhibitors/ARBs/ARNI, beta-blockers, mineralocorticoid receptor antagonists, and SGLT2 inhibitors, as this is the first-line treatment for both the severe LV dysfunction and secondary tricuspid regurgitation 1, 2
• Aggressively titrate loop diuretics (furosemide or equivalent) to relieve systemic and hepatic congestion, as these are the cornerstone for managing right-sided heart failure symptoms and the small pericardial effusion 3, 1
• Add aldosterone antagonists for additional volume management, particularly given the elevated right atrial pressure (15 mmHg) and hepatic congestion risk, which promotes secondary hyperaldosteronism 3, 1

Addressing Elevated Pulmonary Pressures

• Optimize treatment of left-sided filling pressures through aggressive GDMT, as the elevated PA systolic pressure (46 mmHg) is likely secondary to the severe LV dysfunction with grade II diastolic dysfunction 3
• Medical therapies to reduce pulmonary artery pressures might be considered if pulmonary hypertension persists despite optimization of left-sided disease, though evidence is limited (Class IIb) 3

Critical Assessment Parameters

Why Surgery is NOT Currently Indicated

Surgical intervention is contraindicated at this time due to several high-risk features 3, 1:

• Severely reduced LVEF (30-35%) places the patient at extremely high perioperative mortality risk
• Significant RV dysfunction (TAPSE 1.6 cm, well below the normal threshold of >1.6-1.7 cm; RV fractional area 35%, below normal >35%; mild-moderate RV systolic dysfunction) indicates poor surgical candidacy 3, 1
• Moderate-to-severe functional tricuspid regurgitation in the setting of biventricular failure is unlikely to improve outcomes with isolated tricuspid surgery when severe ventricular dysfunction is present 3, 1
• Reoperation for isolated TR after addressing left-sided disease carries 10-25% perioperative mortality, and primary surgery in this context would be even higher risk 1

Monitoring Parameters During Medical Optimization

Serial echocardiography every 3-6 months to assess 1, 2:

• LV ejection fraction recovery - improvement to >40% would change surgical candidacy
• RV function parameters - TAPSE, S' velocity, RV fractional area, and RV free wall longitudinal strain (more sensitive than TAPSE alone) 1, 2
• TR severity progression - vena contracta, EROA, regurgitant volume, hepatic vein flow patterns 3, 1
• Pulmonary artery pressures - reduction with medical therapy would improve prognosis 3, 2
• Right atrial pressure estimation via IVC size and collapsibility 3

Clinical parameters to monitor 1, 2:

• Functional capacity and NYHA class
• Signs of progressive right heart failure (worsening edema, ascites, hepatic congestion)
• Liver function tests for hepatic dysfunction from chronic congestion
• BNP/NT-proBNP levels

Potential Future Surgical Considerations

If Ventricular Function Improves

Tricuspid valve surgery would become appropriate if 3, 1:

• LVEF improves to >40% with medical therapy
• RV function improves (TAPSE >1.7 cm, improved fractional area)
• Patient remains symptomatic with severe TR despite optimal medical therapy
• Progressive RV dilation occurs despite medical management

Tricuspid valve repair with a rigid or semi-rigid prosthetic ring is the preferred surgical approach when intervention becomes feasible, as it provides superior outcomes compared to flexible bands or valve replacement 3, 1

If Left-Sided Valve Surgery Becomes Necessary

Concomitant tricuspid valve repair is strongly recommended (Class I, Level B-NR) if the patient requires mitral valve surgery for the moderate mitral regurgitation, given the moderate-to-severe TR and dilated tricuspid annulus 3, 1

Transcatheter Options

Consider referral to a tertiary heart valve center with transcatheter tricuspid valve intervention (TTVI) expertise if the patient remains symptomatic with severe TR despite optimal medical therapy but remains too high-risk for surgery due to persistent severe ventricular dysfunction 1, 4

Emerging transcatheter options include edge-to-edge repair, annuloplasty devices, and caval valve implantation, though long-term data are still evolving 4

Common Pitfalls to Avoid

• Do not delay medical optimization in favor of early surgical evaluation - the severely reduced biventricular function makes surgery extremely high-risk currently 1
• Do not attribute all symptoms solely to TR - the severe LV dysfunction with elevated filling pressures is the primary driver of symptoms and must be aggressively treated 5
• Do not underestimate the importance of RV function assessment - TAPSE alone may underestimate RV dysfunction; incorporate RV free wall longitudinal strain when available 1, 6
• Do not operate if severe irreversible RV dysfunction or irreversible pulmonary hypertension develops, as surgery would be futile 1
• Do not use flexible annuloplasty bands if surgery eventually becomes appropriate - rigid or semi-rigid rings have superior durability 1

Prognosis and Counseling

The combination of severe biventricular dysfunction, significant TR, and elevated pulmonary pressures portends poor prognosis 4, 7. However, aggressive medical optimization may lead to reverse remodeling and improved ventricular function, potentially making the patient a surgical candidate in the future 1, 2, 8

Functional TR in the setting of severe LV dysfunction often improves with optimization of left-sided disease, though the moderate-to-severe degree present here may not fully resolve 2, 5