What is the best course of treatment for a patient with increased central venous pressure, a dilated right ventricle, severe tricuspid regurgitation, and right heart failure, with a left ventricular ejection fraction (LVEF) of 60%?

Management of Right Heart Failure with Severe Tricuspid Regurgitation and Preserved LVEF

For a patient with right heart failure, severe tricuspid regurgitation, dilated right ventricle, elevated central venous pressure, and preserved LVEF (60%), tricuspid valve surgery should be strongly considered to reduce symptoms and prevent recurrent hospitalizations, as this represents symptomatic severe isolated primary or secondary TR without severe RV dysfunction. 1

Immediate Assessment Priorities

Determine TR Etiology and Severity

• Distinguish primary versus secondary TR by evaluating tricuspid valve morphology on echocardiography—look for leaflet abnormalities, flail leaflets, or prolapse (primary) versus structurally normal leaflets with annular dilation (secondary) 1, 2
• Confirm severe TR using multiple criteria: vena contracta ≥7 mm, EROA ≥0.4 cm², regurgitant volume ≥45 mL/beat, hepatic vein systolic flow reversal, dense continuous-wave Doppler signal with triangular shape, and dilated right heart chambers 1
• Measure tricuspid annular diameter—if ≥40 mm or >21 mm/m², this indicates significant annular dilation regardless of apparent TR severity 1, 3

Evaluate RV Function and Pulmonary Hemodynamics

• Assess RV systolic function using TAPSE (tricuspid annular plane systolic excursion), RV free wall longitudinal strain, and 3D echocardiography or cardiac MRI for RV volumes 1, 4
• Perform right heart catheterization to directly measure pulmonary artery pressures, pulmonary vascular resistance, right atrial pressure, and cardiac index when clinical and non-invasive data are discordant or inadequate 1, 5
• Identify severe RV dysfunction (a contraindication to surgery)—look for severely reduced TAPSE (<14 mm), severely reduced RV ejection fraction, or massive RV dilation with poor contractility 1
• Exclude severe pulmonary hypertension or pulmonary vascular disease (systolic PAP >60 mmHg with elevated PVR) as this significantly increases surgical risk and may represent a contraindication 1

Surgical Intervention Criteria

Class I Indications (Strongest Recommendations)

• Surgery is indicated for symptomatic patients with severe isolated primary TR without severe RV dysfunction 1
• This patient has right heart failure symptoms (elevated CVP, RV dilation) with preserved LVEF, making them a surgical candidate if RV function is not severely impaired 1

Class IIa Indications (Should Be Considered)

• Surgery should be considered for symptomatic patients with severe isolated secondary TR attributable to annular dilation in the absence of severe pulmonary hypertension or left-sided disease 1
• Surgery should be considered for asymptomatic or mildly symptomatic patients with severe isolated primary TR and progressive RV dilation or deterioration of RV function 1

Critical Timing Considerations

• Early surgical intervention is crucial to avoid irreversible RV dysfunction, organ failure, and poor results from late surgical intervention 1, 3
• Delaying surgery until severe RV dysfunction develops results in high operative mortality (potentially >20%) and poor long-term outcomes 1, 6
• Mean survival from diagnosis of severe TR is only 4.35 years, and from symptom onset is 2.28 years, with heart failure being the most common cause of death (50%) 6

Medical Management (Temporizing Measures)

Diuretic Therapy

• Diuretics are the cornerstone of medical therapy to reduce systemic congestion and improve symptoms in right-sided heart failure 1, 2
• However, diuretics provide only symptomatic relief and do not address the underlying valve pathology or prevent disease progression 1, 6

Additional Medical Considerations

• Treat underlying conditions such as atrial fibrillation (present in 70.5% of severe TR patients), which may require rate control, rhythm control, or anticoagulation 6, 2
• Optimize volume status carefully—excessive diuresis can reduce preload and worsen cardiac output in RV failure 7
• Consider pulmonary vasodilators only if pulmonary hypertension is documented and contributing to RV pressure overload 7

Transcatheter Intervention

Limited Role in This Clinical Scenario

• Transcatheter tricuspid valve repair may be considered only in symptomatic patients with severe secondary TR who are inoperable or at prohibitive surgical risk at a heart valve center with dedicated expertise 1, 2
• This is a Class IIb recommendation (may be considered), indicating weaker evidence than surgical intervention 1
• Not appropriate as first-line therapy when the patient is a reasonable surgical candidate 1

Critical Pitfalls to Avoid

Do Not Delay Surgery

• Avoid the misconception that TR will improve with medical therapy alone—once the tricuspid annulus is significantly dilated, it cannot spontaneously return to normal and may continue to dilate 8
• Do not wait for "more severe" symptoms—by the time severe RV dysfunction develops, surgical outcomes are significantly worse 1, 3, 6

Recognize the Vicious Cycle

• Understand that severe TR creates progressive RV volume overload leading to further RV dilation, worsening TR, and ultimately irreversible RV dysfunction 3, 2
• Symptomatic patients have significantly increased mortality, prolonged hospitalization, and rehospitalization rates (36.8% rehospitalization rate in one study) 6

Assess for Concomitant Pathology

• Exclude left-sided valve dysfunction that may have been missed or developed since any prior cardiac surgery 1
• Evaluate for pacemaker leads crossing the tricuspid valve, which can contribute to TR progression 3

Recommended Management Algorithm

1. Confirm severe TR and assess RV function with comprehensive echocardiography including TAPSE, RV strain, and annular diameter 1, 4
2. Perform right heart catheterization to measure pulmonary pressures, PVR, and cardiac index 1, 5
3. If severe RV dysfunction or severe pulmonary vascular disease is present, surgery carries prohibitive risk—consider transcatheter options or medical management only 1
4. If RV function is preserved or only moderately impaired, refer urgently to cardiac surgery for tricuspid valve repair (preferably ring annuloplasty) 1, 3
5. Initiate diuretic therapy for symptom relief while awaiting surgical evaluation 1
6. Do not delay surgical referral beyond stabilization of acute decompensation, as outcomes worsen with progressive RV dysfunction 1, 3, 6