What is the British Society of Echocardiography (BSE) guidance for managing a patient with moderate tricuspid regurgitation (TR)?

BSE Guidance on Moderate Tricuspid Regurgitation

Primary Recommendation

Surgery should be considered (Class IIa) for patients with moderate TR undergoing left-sided valve surgery, particularly when the tricuspid annulus is dilated ≥40 mm or ≥21 mm/m². 1, 2

Classification and Initial Assessment

The British Society of Echocardiography approach aligns with European guidelines in distinguishing between:

• Primary (organic) TR: Structural valve abnormalities including leaflet damage, chordal rupture, vegetation, or congenital abnormalities 2
• Secondary (functional) TR: Results from annular dilation and/or leaflet tethering without primary valve pathology, most commonly associated with right ventricular dilation 2

Echocardiographic evaluation must assess:

• Tricuspid annular diameter (critical threshold: ≥40 mm or ≥21 mm/m²) 1, 2
• Right ventricular size and function (TAPSE, S' velocity, RV free wall strain) 1, 2
• Pulmonary artery systolic pressure 1
• Structural valve abnormalities to distinguish primary from secondary TR 1
• Hepatic vein flow patterns 1

Management Algorithm for Moderate TR

Scenario 1: Moderate TR + Planned Left-Sided Valve Surgery

Concomitant tricuspid valve repair is recommended (Class IIa) when:

• Tricuspid annulus ≥40 mm or ≥21 mm/m² 1, 2
• Moderate primary (organic) TR is present 1

Surgical technique:

• Ring annuloplasty with rigid or semi-rigid prosthetic rings is preferred over flexible bands 2
• Valve repair is superior to replacement when feasible 1, 2

Critical pitfall to avoid: Failing to address moderate TR with annular dilation during left-sided valve surgery leads to 10-25% perioperative mortality if reoperation becomes necessary 2, 3

Scenario 2: Isolated Moderate TR (No Left-Sided Surgery Planned)

Medical management is the primary approach:

• Guideline-directed medical therapy for heart failure if present 2
• Loop diuretics for symptom relief if right-sided congestion develops 2
• Rhythm control strategies if atrial fibrillation is present, as AF-induced annular remodeling drives TR progression 2

Surgery is NOT indicated for isolated moderate TR without symptoms or progressive RV dysfunction 1, 2

Surveillance Parameters

Serial echocardiographic monitoring should assess:

• Progression to severe TR (vena contracta ≥7 mm, EROA ≥0.4 cm², central jet ≥50% RA) 2
• Tricuspid annular diameter progression to ≥40 mm or ≥21 mm/m² 2
• RV function deterioration (TAPSE <17 mm, S' velocity <10 cm/s) 2
• Development of pulmonary hypertension (PASP >35-40 mmHg) 2
• Clinical signs of right heart failure (peripheral edema, ascites, hepatomegaly, jugular venous distension) 2

When Intervention Becomes Indicated

Surgical intervention is warranted if moderate TR progresses to:

• Severe symptomatic TR with preserved RV function 1, 2
• Progressive RV dilation or systolic dysfunction despite medical management 1, 2
• Need for left-sided valve surgery develops (with annular dilation ≥40 mm) 1, 2

Absolute contraindications to surgery:

• Severe irreversible RV dysfunction 2, 3
• Irreversible pulmonary hypertension (systolic PAP >60 mmHg) 1, 3
• Irreversible liver dysfunction from chronic hepatic congestion 2, 3

Key Clinical Pitfalls

Do not operate on isolated moderate TR without symptoms or RV dysfunction - the surgical risk exceeds potential benefit 2, 4

Do not delay addressing moderate TR with annular dilation during planned left-sided valve surgery - this is the most common and devastating error, as reoperation carries significantly higher mortality 2, 3

Do not assume functional TR will resolve after treating left-sided disease - this traditional teaching has proven incorrect, and prophylactic repair during left-sided surgery prevents progression 2, 5