What is the management plan for a patient with moderate tricuspid regurgitation (TR)?

Management of Moderate Tricuspid Regurgitation

For moderate TR with preserved right ventricular function and no pulmonary hypertension, medical management with close surveillance is the appropriate strategy—surgical intervention is not indicated unless TR progresses to severe or the patient requires left-sided valve surgery. 1

Initial Assessment and Risk Stratification

When evaluating moderate TR, the critical determinants are:

• Right ventricular function: Normal is defined as TAPSE ≥17 mm and S' velocity ≥10 cm/s 1
• Pulmonary artery pressure: Normal is PASP <35-40 mmHg 1, 2
• Symptom status: Absence of NYHA class III-IV symptoms or signs of right heart failure 1
• TR etiology: Distinguish between primary (organic valve pathology) versus secondary (functional, due to annular dilation or RV dysfunction) 1

Patients with moderate TR who have preserved RV function, normal pulmonary pressures, and no symptoms do not meet criteria for surgical intervention according to ACC/AHA and ESC guidelines. 1, 2

Medical Management Strategy

First-Line Therapy

• Guideline-directed medical therapy for heart failure should be initiated as first-line treatment for both primary and secondary isolated TR 1
• Diuretics (particularly loop diuretics) are recommended for symptom relief if any volume overload or congestion is present 1
• Aldosterone antagonists may provide additive benefit, especially when hepatic congestion develops 1
• Rhythm control strategies should be implemented in patients with concurrent atrial fibrillation, as AF-induced annular remodeling is a major driver of secondary TR progression 1

The goal is to prevent progression while maintaining quality of life. Medical therapy should be optimized but does not delay referral for intervention if severe TR develops. 1

Activity and Exercise Recommendations

Regular endurance-type exercise is reasonable and not contraindicated in moderate TR with preserved RV function. 2

• Current guidelines reserve exercise restriction for severe valvular disease or symptomatic heart failure—moderate TR does not fall into this category 2
• Recommended activities include walking, cycling, or swimming at conversational pace 2
• Avoid high-intensity interval training or competitive athletics that could acutely increase right-sided pressures 2
• Light resistance training with higher repetitions is acceptable, but avoid heavy weights 2

Exercise should be restricted only if symptoms develop (NYHA class III-IV), progressive RV dysfunction occurs, or TR progresses to severe. 2

Critical Monitoring Parameters

Serial echocardiographic surveillance is essential to detect progression that would trigger intervention. Monitor every 1-3 years or sooner if symptoms develop: 1, 2

Key Thresholds for Progression

• TR severity progression: Vena contracta ≥7 mm, EROA ≥0.4 cm², or central jet ≥50% of right atrium defines severe TR 1
• Tricuspid annular diameter: Progression to ≥40 mm (or ≥21 mm/m² indexed) is a critical threshold—if this occurs and the patient requires left-sided valve surgery, concomitant tricuspid repair should be performed (Class IIa) 1, 2
• RV function deterioration: TAPSE <17 mm or S' velocity <10 cm/s indicates worsening RV dysfunction 1
• Pulmonary hypertension development: PASP >35-40 mmHg changes the hemodynamic burden 1, 2
• Symptom development: New dyspnea, fatigue, peripheral edema, or ascites 1

RV free wall longitudinal strain from 2D speckle-tracking echocardiography provides more sensitive assessment of RV function than TAPSE alone and should be used when available. 1, 3

Indications for Surgical Intervention

Surgical intervention becomes appropriate when: 1

Class I Indications (Strong Recommendations)

• Severe TR with symptoms (NYHA class III-IV) and preserved RV function without severe irreversible RV dysfunction or irreversible pulmonary hypertension 1
• Severe TR in patients undergoing left-sided valve surgery, regardless of symptoms (Class I, Level B-NR per ACC/AHA; Class I, Level C per ESC) 1

Class IIa Indication (Moderate Recommendation)

• Moderate TR with tricuspid annular dilation ≥40 mm (or ≥21 mm/m²) in patients undergoing left-sided valve surgery—concomitant tricuspid repair should be considered to prevent subsequent TR progression 1, 2

Surgical Approach When Indicated

• Tricuspid valve repair with rigid or semi-rigid ring annuloplasty is the preferred first-line surgical approach, as it provides superior outcomes compared to flexible bands or valve replacement 1
• Valve replacement is reserved for severe RV dysfunction, very large annuli, significant leaflet tenting, or valve destruction 1, 3

Common Pitfalls to Avoid

• Do not unnecessarily restrict activity based solely on the diagnosis of moderate TR without functional impairment—this leads to deconditioning and reduced quality of life without proven benefit 2
• Do not delay surgical evaluation if TR progresses to severe with symptoms and preserved RV function, as progressive RV dysfunction worsens surgical outcomes 1
• Do not miss the opportunity for concomitant tricuspid repair during left-sided valve surgery when annular dilation ≥40 mm is present—reoperation for isolated TR carries 10-25% perioperative mortality 1
• Do not perform TV surgery in patients with only tricuspid annular dilation but absent or trace TR 1

Emerging Transcatheter Options

For patients who progress to severe symptomatic TR but are high surgical risk, transcatheter tricuspid valve intervention (TTVI) may be considered at specialized heart valve centers (Class IIb, Level C per ESC). 3, 4 However, these devices have not yet demonstrated mortality or heart failure hospitalization benefit, and their role continues to evolve. 4

Natural History and Prognosis

The natural history of moderate functional TR involves early atrial enlargement and tricuspid annular dilation, followed by late RV dilation when TR becomes severe. 1 In patients with heart failure, moderate to severe TR is associated with progressively worse survival, with five-year survival of only 34% in severe TR with HFrEF. 4, 5 This underscores the importance of vigilant monitoring and timely intervention when progression occurs.