What is the best management approach for a patient with severe tricuspid regurgitation (TR) and cor pulmonale who experiences paroxysmal atrial fibrillation (AF)?

Management of Paroxysmal Atrial Fibrillation in Severe Tricuspid Regurgitation with Cor Pulmonale

In patients with severe tricuspid regurgitation (TR), cor pulmonale, and paroxysmal atrial fibrillation (AF), prioritize aggressive medical management with guideline-directed heart failure therapy, rhythm control strategies to prevent AF-induced annular remodeling, and early surgical evaluation before irreversible right ventricular dysfunction develops. 1

Initial Medical Management Strategy

Initiate guideline-directed medical therapy (GDMT) for heart failure as the first-line approach, which should not delay referral for surgical or transcatheter intervention when already indicated. 1

Diuretic Therapy

• Administer loop diuretics aggressively to relieve systemic and hepatic congestion, titrating to symptom relief while monitoring for hypotension and worsening renal function. 1
• Add aldosterone antagonists for additional volume management, particularly beneficial when hepatic congestion promotes secondary hyperaldosteronism. 1

Rhythm Control for AF

Pursue rhythm control strategies specifically to contain annular dilatation and prevent TR progression, as AF-induced annular remodeling is a major determinant of secondary TR. 1

• For patients without structural heart disease or with minimal disease, use flecainide, propafenone, or sotalol as first-line antiarrhythmic therapy due to their favorable safety profile and lack of extracardiac toxicity. 1
• For patients with heart failure or reduced ejection fraction, amiodarone or dofetilide are the only safe antiarrhythmic options due to proarrhythmic risks of other agents. 1
• Beta-blockers provide dual benefit through rate control and favorable effects on heart failure morbidity and mortality. 1

Rate Control if Rhythm Control Fails

• If rhythm control is unsuccessful or not pursued, use beta-blockers as first-line for rate control in patients with preserved ejection fraction. 1
• Combine digoxin with beta-blocker if monotherapy provides inadequate rate control, as combination therapy provides better control at rest and during exercise. 1

Anticoagulation Strategy

Initiate oral anticoagulation based on stroke risk assessment, as patients with AF and risk factors benefit from anticoagulation regardless of rhythm status. 1

• Direct oral anticoagulants (DOACs) are preferred over warfarin in eligible patients due to lower risk of intracranial hemorrhage. 2
• Continue anticoagulation indefinitely based on stroke risk factors, not rhythm status, as most strokes occur after anticoagulation is stopped or when subtherapeutic. 1

Surgical Intervention Timing and Indications

When to Refer for Surgery

TV repair with annuloplasty may be considered (Class IIb, Level C) in symptomatic or asymptomatic AF patients with severe TR and progressive RV dysfunction and/or dilation despite GDMT. 1

Surgery should be considered (Class IIa, Level B) for symptomatic patients with severe secondary TR who have RV dilatation in the absence of severe RV or LV dysfunction and severe pulmonary vascular disease/hypertension. 1

Absolute Contraindications to Surgery

• Severe irreversible RV dysfunction makes surgery futile. 1
• Irreversible pulmonary hypertension or severe pulmonary vascular disease contraindicates intervention. 1
• Irreversible liver cirrhosis from chronic hepatic congestion is an absolute contraindication. 1, 3

Surgical Approach When Feasible

TV repair with rigid or semi-rigid ring annuloplasty is the first-line surgical approach, as it provides superior outcomes compared to flexible bands in preventing late recurrent TR. 1, 2

Valve replacement should be considered instead of repair in patients with severe RV dysfunction, very large annuli, or significant leaflet tenting. 1

Transcatheter Tricuspid Valve Intervention (TTVI)

Transcatheter treatment may be considered (Class IIb, Level C) for symptomatic secondary severe TR in inoperable patients at heart valve centers with expertise in TV disease treatment. 1

Refer to tertiary heart valve centers with TTVI expertise for high-risk surgical candidates with severe TR. 1

Critical Monitoring Parameters

Echocardiographic Assessment

• Monitor tricuspid annular diameter, with progression to ≥40 mm (or ≥21 mm/m²) triggering consideration for intervention. 1, 2
• Assess RV function using TAPSE (threshold <17 mm indicates dysfunction) and S' velocity (threshold <10 cm/s indicates dysfunction). 2
• Use RV free wall longitudinal strain from 2D speckle-tracking echocardiography for more sensitive RV function assessment. 1
• Monitor pulmonary artery pressure, with development of pulmonary hypertension (PASP >35-40 mmHg) changing management. 2

Liver Function Assessment

Evaluate liver function using Child-Pugh classification and MELD score to assess for irreversible hepatic dysfunction before considering surgery. 1

Common Pitfalls to Avoid

Delaying surgical evaluation until irreversible hepatic dysfunction or severe RV dysfunction develops is the most devastating error—patients often respond initially to diuretic therapy, creating false reassurance. 3

Do not perform TV surgery in patients with tricuspid annular dilatation but absent or only trace TR, as this is not currently recommended. 1

Avoid flexible annuloplasty bands when rigid/semi-rigid rings are available, as they have higher rates of recurrent TR. 1

Do not use digoxin as the sole agent for rate control in paroxysmal AF, as it is ineffective for this indication. 1

Failing to continue anticoagulation after cardioversion in patients with stroke risk factors increases stroke risk substantially. 1