What is the management approach for a patient with severe tricuspid regurgitation, particularly those who are symptomatic or have evidence of right ventricular dysfunction?

Management of Severe Tricuspid Regurgitation

Surgery is indicated for symptomatic patients with severe tricuspid regurgitation who have preserved right ventricular function, and should be performed early—before irreversible RV dysfunction, end-organ damage, or severe pulmonary hypertension develop. 1, 2

Surgical Indications (Class I Recommendations)

Isolated Severe TR

• Operate on symptomatic patients with severe isolated primary TR without severe RV dysfunction (Class I, Level C). 1, 2
• Delaying surgery despite good diuretic response leads to irreversible RV damage, organ failure, and poor late surgical outcomes. 1
• Surgery should not be performed if severe irreversible RV dysfunction or irreversible pulmonary hypertension is present, as outcomes are futile. 2, 3

Concomitant with Left-Sided Valve Surgery

• Operate on all patients with severe TR (primary or secondary) undergoing left-sided valve surgery, regardless of symptoms (Class I, Level B-NR/C). 1, 2
• This prevents subsequent TR progression and avoids high-risk reoperation (10-25% mortality). 2, 3

After Previous Left-Sided Valve Surgery

• Consider surgery for patients with persistent/recurrent severe TR who are symptomatic or have progressive RV dilatation/dysfunction, provided there is no left-sided valve dysfunction, severe RV/LV dysfunction, or severe pulmonary vascular disease (Class IIa, Level C). 1

Surgical Indications for Moderate TR (Class IIa Recommendations)

• Consider concomitant tricuspid surgery during left-sided valve surgery for:

  • Moderate primary TR (Class IIa, Level C) 1
  • Mild or moderate secondary TR with tricuspid annular dilation ≥40 mm or ≥21 mm/m² (Class IIa, Level C) 1, 2

• Consider surgery for asymptomatic/mildly symptomatic patients with severe isolated primary TR and progressive RV dilatation or deteriorating RV function (Class IIa, Level C). 1

Surgical Technique Selection

Valve Repair vs. Replacement

• Valve repair with rigid or semi-rigid prosthetic ring annuloplasty is the preferred first-line approach when technically feasible, as it provides superior outcomes to flexible bands in preventing late recurrent TR. 1, 2
• Flexible bands should be avoided when rigid/semi-rigid rings are available due to higher recurrence rates. 2

When to Choose Valve Replacement

• Consider valve replacement instead of repair when: 1, 2, 3
  • Severe RV dysfunction is present
  • Very large annuli exist
  • Significant leaflet tethering/tenting is present
  • Valve destruction has occurred (e.g., endocarditis, biopsy injury)
• Large bioprostheses are favored over mechanical valves. 1
• If residual TR is present on intraoperative TEE after repair, immediate conversion to valve replacement is warranted. 4

Medical Management Strategy

First-Line Medical Therapy

• Loop diuretics are the cornerstone for relieving systemic and hepatic congestion, with aggressive titration required for symptom control. 1, 2
• Aldosterone antagonists provide additive benefit, particularly when hepatic congestion promotes secondary hyperaldosteronism. 2, 3
• Guideline-directed medical therapy for heart failure with reduced ejection fraction should be initiated as first-line treatment for both primary and secondary isolated TR. 2
• Rhythm control strategies should be implemented in patients with atrial fibrillation, as AF-induced annular remodeling is a major determinant of secondary TR. 2, 5

Medical Therapy Should Not Delay Surgical Referral

• Medical therapy should not delay surgical or transcatheter referral when intervention is already indicated. 2
• Though patients respond well to diuretics initially, this creates false reassurance—delaying surgery until irreversible hepatic or RV dysfunction develops is the most common and devastating error. 2, 3

Monitoring Parameters to Trigger Intervention

Echocardiographic Thresholds

• TR severity progression: vena contracta ≥7 mm, EROA ≥0.4 cm², regurgitant volume ≥45 mL/beat, central jet ≥50% of right atrium, hepatic vein systolic flow reversal. 2, 5
• RV dysfunction: TAPSE <17 mm, S' velocity <10 cm/s, or RV free wall longitudinal strain deterioration. 2, 5
• Tricuspid annular dilation: ≥40 mm or ≥21 mm/m². 1, 2
• Pulmonary hypertension development: PASP >35-40 mmHg. 2, 5

Clinical Parameters

• Development of symptoms (dyspnea, fatigue, peripheral edema, ascites) indicating right heart failure. 2, 5
• Progressive RV dilatation despite medical management. 1, 2

Transcatheter Tricuspid Valve Intervention (TTVI)

• Refer high-risk surgical patients with severe TR to tertiary heart valve centers with TTVI expertise (Class IIb, Level C). 2, 3
• Recent data from the TRISCEND II trial demonstrated that transcatheter tricuspid-valve replacement was superior to medical therapy alone for the composite outcome, driven primarily by improvements in symptoms and quality of life (win ratio 2.02,95% CI 1.56-2.62, P<0.001). 6
• However, severe bleeding occurred in 15.4% vs. 5.3% (P=0.003) and new permanent pacemakers were required in 17.4% vs. 2.3% (P<0.001) compared to medical therapy. 6

Absolute Contraindications to Surgery

• Severe irreversible RV dysfunction. 2, 3
• Severe and uncorrectable pulmonary hypertension. 2, 3
• Irreversible liver dysfunction or advanced cirrhosis from chronic hepatic congestion. 2, 3
• Severe LV dysfunction in the setting of secondary TR. 1

Critical Pitfalls to Avoid

• Do not delay surgical evaluation in symptomatic patients with severe TR and preserved RV function—progressive RV dysfunction worsens surgical outcomes and may render patients inoperable. 2, 3
• Do not fail to address severe TR at the time of initial left-sided valve surgery—reoperation for isolated TR carries 10-25% perioperative mortality. 2, 3
• Do not perform TV surgery in patients with tricuspid annular dilation but absent or only trace TR—annular dilation alone without significant regurgitation is not an indication. 2, 3
• Do not use flexible annuloplasty bands when rigid/semi-rigid rings are available—they have higher rates of recurrent TR. 2
• Do not aggressively diurese patients with low-output states—this precipitates hypotension and worsening renal function. 3

Algorithmic Approach to Decision-Making

1. Assess TR severity using comprehensive echocardiography (vena contracta, EROA, regurgitant volume, hepatic vein flow). 2
2. Evaluate RV function (TAPSE, S' velocity, RV free wall strain) and pulmonary pressures. 2, 5
3. Determine if left-sided valve surgery is planned:
   • If yes → repair/replace tricuspid valve if severe TR present, or if moderate TR with annular dilation ≥40 mm. 1, 2
4. For isolated severe TR:
   • If symptomatic + preserved RV function → surgery (Class I). 1, 2
   • If asymptomatic but progressive RV dilatation/dysfunction → consider surgery (Class IIa). 1
   • If severe irreversible RV dysfunction or pulmonary hypertension → consider TTVI or medical management only. 2, 3, 6
5. Assess surgical risk:
   • Low-moderate risk → surgical repair/replacement. 2, 7
   • High risk/inoperable → refer for TTVI evaluation. 2, 3, 6
6. Optimize medical therapy with loop diuretics, aldosterone antagonists, GDMT for HF, and rhythm control for AF regardless of intervention timing. 2, 5