What is the best treatment approach for a patient with severe tricuspid regurgitation and symptoms of right ventricular dysfunction?

Treatment of Severe Tricuspid Regurgitation with RV Dysfunction

Surgery is indicated for symptomatic patients with severe tricuspid regurgitation without severe right ventricular dysfunction, with valve repair using prosthetic ring annuloplasty preferred over replacement. 1

Initial Assessment and Classification

Before determining treatment, distinguish between primary (organic) and secondary (functional) tricuspid regurgitation, as this affects surgical approach and prognosis. 2, 3

• Primary TR results from structural valve abnormalities including leaflet damage, chordal rupture, vegetation, or congenital abnormalities 2
• Secondary TR results from annular dilation and/or leaflet tethering without primary valve pathology, most commonly from RV dilation and dysfunction 2

Medical Management as Initial Therapy

Guideline-directed medical therapy for heart failure should be initiated first-line for both primary and secondary isolated TR, but should not delay surgical referral when intervention is already indicated. 2

• Loop diuretics are the cornerstone for relieving systemic and hepatic congestion, requiring aggressive titration to relieve symptoms 1, 2
• Aldosterone antagonists provide additive benefit, particularly when hepatic congestion is present due to secondary hyperaldosteronism 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 2

Surgical Intervention Indications

Class I Recommendations (Strongest Evidence)

Surgery is indicated in the following scenarios:

• Symptomatic patients with severe isolated primary TR without severe RV dysfunction (Class I, Level C) 1
• Patients with severe TR (primary or secondary) undergoing left-sided valve surgery regardless of symptoms (Class I, Level C) 1
• Patients with severe tricuspid stenosis undergoing left-sided valve intervention (Class I, Level C) 1

Class IIa Recommendations (Should Be Considered)

Surgery should be considered in:

• Asymptomatic or mildly symptomatic patients with severe isolated primary TR and progressive RV dilatation or deterioration of RV function (Class IIa, Level C) 1
• Patients with moderate primary TR undergoing left-sided valve surgery (Class IIa, Level C) 1
• Patients with mild or moderate secondary TR with dilated annulus (≥40 mm or >21 mm/m²) undergoing left-sided valve surgery (Class IIa, Level C) 1
• After left-sided valve surgery, patients with severe TR who are symptomatic or have progressive RV dilatation/dysfunction, in the absence of left-sided valve dysfunction, severe RV or LV dysfunction, and severe pulmonary vascular disease (Class IIa, Level C) 1

Critical Timing Considerations

Delaying surgery in symptomatic patients with severe TR and preserved RV function leads to irreversible RV damage, organ failure, and poor results of late surgical intervention. 1

• Though patients respond well to diuretic therapy initially, this should not delay surgical evaluation 1
• Surgery should be carried out early enough to avoid irreversible RV dysfunction 1
• Reoperation for isolated TR after previous left-sided valve surgery carries 10-25% perioperative mortality, emphasizing the importance of addressing severe TR at the time of initial left-sided valve surgery 2

Surgical Technique Selection

Valve repair with prosthetic ring annuloplasty is preferred over valve replacement when technically feasible. 1, 2

Ring Annuloplasty (Preferred Approach)

• Rigid or semi-rigid prosthetic rings are superior to flexible bands or suture annuloplasty, with residual TR rates of 10% versus 20-35% at 5 years 1, 2
• Ring annuloplasty is key to surgery for secondary TR related to isolated tricuspid annular dilatation 1
• Flexible bands should not be used when rigid/semi-rigid rings are available due to higher rates of recurrent TR 2

Valve Replacement Indications

Valve replacement should be considered when:

• Tricuspid valve leaflets are significantly tethered and the annulus is severely dilated 1
• Severe RV dysfunction is present 2
• Very large annuli exist 2
• Significant leaflet tenting occurs 2
• Valve destruction is present 2

Biological prostheses are usually preferred over mechanical ones due to the high risk of thrombosis with mechanical valves and satisfactory long-term durability of bioprostheses in the tricuspid position 1

Contraindications to Surgery

Do not operate if the following are present:

• Severe irreversible RV dysfunction 2
• Irreversible pulmonary hypertension 2
• Irreversible liver dysfunction from chronic hepatic congestion 2
• Surgery is likely futile in these scenarios 2

Transcatheter Tricuspid Valve Intervention (TTVI)

For high-risk surgical patients with severe TR, referral to tertiary heart valve centers with TTVI expertise should be considered. 2, 4, 5

Recent Evidence for Transcatheter Valve Replacement

The 2025 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. 6

Key findings:

• Improvements in KCCQ-OS score (23.1% vs. 6.0% wins) 6
• Improvements in NYHA class (10.2% vs. 0.8% wins) 6
• Important complications: severe bleeding in 15.4% and new permanent pacemakers in 17.4% 6

Current Status of Percutaneous Techniques

• Percutaneous repair techniques (edge-to-edge repair, annuloplasty devices) are in their infancy and must be further evaluated before formal recommendations can be made 1
• These technologies are broadly categorized into direct suture annuloplasty devices, minimally invasive annuloplasty, direct ring annuloplasty devices, coaptation-based strategies, edge-to-edge repair devices, and transcatheter valve replacement 4
• Transcatheter tricuspid valve intervention is emerging as a reliable option for high-risk patients with isolated primary TR or with secondary TR related to advanced left-sided heart valve disease 3

Monitoring Parameters During Medical Management

Serial transthoracic echocardiography should monitor:

• TR severity progression: vena contracta ≥7 mm, EROA ≥0.4 cm², central jet ≥50% of right atrium 2
• RV function: TAPSE <17 mm or S' velocity <10 cm/s indicates worsening RV function 2
• Tricuspid annular diameter: progression to ≥40 mm (or ≥21 mm/m²) triggers consideration for intervention if left-sided surgery becomes necessary 2
• Pulmonary artery pressure: development of pulmonary hypertension (PASP >35-40 mmHg) changes management 2
• RV free wall longitudinal strain from 2D speckle-tracking echocardiography provides more sensitive RV function assessment than TAPSE alone 2

Common Pitfalls to Avoid

• Do not perform TV surgery in patients with tricuspid annular dilation but absent or only trace TR 2
• Do not delay surgical evaluation in symptomatic patients with severe TR and preserved RV function, as this leads to progressive RV dysfunction and worsens surgical outcomes 2
• Do not use flexible bands when rigid/semi-rigid rings are available 2
• Do not operate if severe irreversible RV dysfunction or irreversible pulmonary hypertension is present 2