What is the best course of treatment for an elderly patient with a history of cardiac conditions, presenting with worsening shortness of breath, global left ventricular hypokinesis, mild decrease in left ventricular systolic function, severe tricuspid valve regurgitation, and secondary pulmonary hypertension?

Management of Elderly Patient with Severe Tricuspid Regurgitation and Secondary Pulmonary Hypertension

This patient requires urgent evaluation for tricuspid valve intervention given the severe device-induced tricuspid regurgitation with secondary pulmonary hypertension, combined with optimization of guideline-directed medical therapy for heart failure with mildly reduced ejection fraction. 1

Immediate Priorities

Address the Primary Mechanical Problem

• The severe tricuspid regurgitation is directly caused by the cardiac device lead interacting with the septal tricuspid leaflet, creating a mechanical problem that requires surgical or interventional correction. 2
• Severe tricuspid regurgitation with secondary pulmonary hypertension in the setting of device-lead interaction represents a class IIa indication for surgical intervention when symptoms are present and right ventricular function is declining. 2
• The combination of severe right and left atrial enlargement, mildly decreased RV function, and worsening dyspnea indicates hemodynamic compromise requiring intervention beyond medical management alone. 2

Optimize Volume Status and Hemodynamics

• Initiate or uptitrate loop diuretics (furosemide starting 40-80 mg daily) to address volume overload from severe tricuspid regurgitation and biventricular dysfunction. 1, 3
• The European Society of Cardiology recommends loop diuretics over thiazides in elderly patients with renal impairment and heart failure, with careful monitoring to avoid excessive preload reduction. 1
• Monitor standing and supine blood pressure closely, as elderly patients with severe valvular disease are particularly susceptible to orthostatic hypotension with diuretic therapy. 4

Guideline-Directed Medical Therapy for HFmrEF

RAAS Blockade

• Start or optimize ACE inhibitor or ARB therapy with careful dose titration and monitoring of renal function and potassium. 1
• The European Society of Cardiology recommends ACE inhibitors or ARBs as first-line therapy in heart failure with renal impairment, with monitoring within 1 week of any dose change. 1, 5
• Avoid triple RAAS blockade (ACE inhibitor + ARB + mineralocorticoid receptor antagonist) due to increased hyperkalemia risk in elderly patients. 1

Beta-Blocker Therapy

• Initiate beta-blocker at low dose with gradual titration once volume status is optimized and the patient is hemodynamically stable. 1
• The American College of Cardiology confirms beta-blockers are well-tolerated in elderly patients with heart failure when started at low doses. 1
• Delay beta-blocker initiation until after device optimization or intervention, as the patient may benefit from cardiac resynchronization therapy given the global LV hypokinesis and reduced ejection fraction. 2

Mineralocorticoid Receptor Antagonist

• Consider adding spironolactone 12.5-25 mg daily after optimizing ACE inhibitor/ARB and beta-blocker, provided renal function permits (eGFR >30 mL/min/1.73 m²). 1
• Monitor potassium and renal function closely within 1 week of initiation given the patient's age and potential renal impairment. 5

SGLT2 Inhibitor

• Add empagliflozin 10 mg daily or dapagliflozin 10 mg daily as first-line therapy for heart failure with mildly reduced ejection fraction. 5
• SGLT2 inhibitors provide mortality benefit in heart failure regardless of diabetes status and are particularly beneficial in patients with renal impairment. 5

Device and Structural Intervention Planning

Evaluate for Tricuspid Valve Repair or Replacement

• Refer to cardiac surgery or interventional cardiology for evaluation of tricuspid valve intervention, as the device-lead induced regurgitation may require lead repositioning, extraction, or valve repair/replacement. 2
• The presence of severe tricuspid regurgitation with symptoms, declining RV function, and progressive atrial enlargement represents a class IIa indication for intervention in experienced centers. 2
• Consider transcatheter tricuspid valve repair if surgical risk is prohibitive given the patient's age and comorbidities. 2

Assess for Cardiac Resynchronization Therapy

• Given the global LV hypokinesis and LVEF ~50% with device already in place, evaluate whether upgrading to biventricular pacing would provide benefit. 2
• The 2023 AHA/ACC/HFSA guidelines recommend resynchronization pacing in patients with reduced ejection fraction and conduction abnormalities to improve symptoms and ventricular function. 2

Monitoring and Follow-Up

Short-Term Monitoring (Within 1-2 Weeks)

• Check renal function (creatinine, BUN, eGFR) and electrolytes (sodium, potassium) within 1 week of any medication change. 1, 5
• Measure standing and supine blood pressure to detect orthostatic hypotension from diuretic therapy. 4, 5
• Repeat NT-proBNP in 4-6 weeks to assess response to medical therapy. 5

Intermediate Monitoring (4-6 Weeks)

• Repeat echocardiogram to assess response to medical therapy and progression of tricuspid regurgitation and RV function. 5
• Evaluate for signs of worsening cardiac decompensation including increased dyspnea, peripheral edema, or decreased exercise tolerance. 4

Long-Term Management

• Schedule more frequent follow-up visits (every 2-3 months initially) given the patient's advanced age, complex valvular disease, and device-related complications. 1
• Emphasize sodium restriction to <2-3 grams daily to reduce fluid retention. 5
• Ensure medication adherence and avoid nephrotoxic drugs including NSAIDs. 5

Critical Pitfalls to Avoid

• Do not delay tricuspid valve intervention in favor of medical management alone when severe device-induced regurgitation is present with declining RV function. 2
• Avoid excessive diuresis that could precipitate hypotension, acute kidney injury, or reduced cardiac output in the setting of severe valvular disease. 2, 1
• Do not use vasopressors like phenylephrine in this patient, as increased afterload could precipitate acute cardiac decompensation in the setting of severe LV hypokinesis and valvular disease. 4
• Monitor for atrial arrhythmias given the severe biatrial enlargement, as atrial fibrillation would significantly worsen hemodynamics and require anticoagulation. 2