From the Guidelines
For tricuspid clip referral as a noninvasive cardiologist, I recommend a stepwise approach focusing on patients with symptomatic severe tricuspid regurgitation (TR) who remain symptomatic despite optimal medical therapy, as outlined in the most recent guidelines 1.
Key Considerations
- Optimize heart failure medications including diuretics, ACE inhibitors/ARBs, beta-blockers, and aldosterone antagonists at guideline-directed doses.
- Patients should demonstrate persistent symptoms (NYHA class II-IV) despite at least 3 months of optimal medical therapy.
- Echocardiographic criteria for referral should include severe TR with specific parameters such as vena contracta width, effective regurgitant orifice area, regurgitant volume, and prominent systolic flow reversal in hepatic veins.
Referral Criteria
- Suitable valve anatomy for clip placement includes primary or secondary TR with leaflet coaptation gap <10mm and leaflet length ≥10mm.
- Consider referral for patients with right ventricular dysfunction (TAPSE <17mm), right ventricular dilation, elevated right atrial pressure, or signs of right heart failure despite medical therapy.
Exclusion Criteria
- Exclude patients with severe pulmonary hypertension (PASP >60mmHg), severe left ventricular dysfunction (LVEF <30%), or significant mitral valve disease requiring intervention.
Guideline Recommendations
- The American and European guidelines propose different classes of recommendation for TV surgery in patients with severe primary or secondary TR, with considerations for symptoms, RV dilation, and prior signs of right-sided heart failure 1.
- The most recent guidelines suggest that transcatheter treatment of symptomatic secondary severe TR in inoperable patients at a heart valve center with dedicated expertise may be considered (Class IIb-C) 1.
From the Research
Tricuspid Clip Referral Algorithm
The best algorithm for Tricuspid clip referral as a Noninvasive Cardiologist involves the following steps:
- Early diagnosis and mechanical correction of Tricuspid Regurgitation (TR) is essential in impacting the natural history of this valvular condition 2
- Multi-modality imaging, in particular echocardiography, is paramount in determining the mechanism, severity, and potential treatment options of TR 2
- Patients with symptomatic severe TR often have multiple comorbidities and present with advanced tricuspid valve and right ventricular remodelling, thus limiting the treatment and prognosis 2, 3
- Transcatheter edge-to-edge repair has emerged as a treatment option for TR, with devices such as the TriClip (Abbott Labs) showing potential as an alternative treatment in high-risk patients 4
Patient Selection
When selecting patients for Tricuspid clip referral, consider the following:
- Patients with severe TR and high surgical risk may benefit from transcatheter repair or replacement 5
- Echocardiography can assess the TR etiology/severity, measure RA and RV size and function, estimate pulmonary pressure, and characterize LV disease 5
- Patients with progressive RV dilatation without severe LV dysfunction and pulmonary hypertension may be considered for surgical annuloplasty or valve replacement 5
- Transcatheter repair/replacement is possible in patients with a LVEF <40%, dilated annuli, and impaired RV function 5
Referral Timing
The timing of referral for Tricuspid clip is crucial:
- Early referral is essential to impact the natural history of severe TR 2
- Patients with chronic tricuspid regurgitation and right ventricular failure may benefit from transcatheter interventions, and referral should be considered before the condition progresses 6
- Primary care providers should be aware of which patients could potentially benefit from tricuspid valve intervention for tricuspid regurgitation for optimal referral and treatment 6