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Tricuspid
Regurgitation

Tricuspid Regurgitation (TR) is a complex disease that has multiple causes, and is associated with high rates of morbidity and mortality.1,2 TR is highly prevalent, and among valve diseases, is one of the most undertreated.1,3 If left untreated, TR initiates a cascade of events that can lead to right-sided Heart Failure (HF) and death.4

Summary of current relevant international guidelines on the diagnosis of TR

2021 ESC/EACTS Guidelines for the Management of VHD39
  1. TR should be evaluated first by echocardiography. In primary TR, specific abnormalities of the valve can be identified. In secondary TR, annular dilatation, along with RV and RA dimensions, as well as RV function should be measured, owing to their prognostic relevance.
  2. In experienced laboratories, RV strain and/or 3D measurements of RV volumes may be considered to overcome the existing limitations of conventional RV function indices. When available, CMR is the preferred method to assess the RV due to its high accuracy and reproducibility.
  3. Echocardiographic criteria for grading severity of TR:
    • Qualitative: tricuspid valve morphology, color flow regurgitant jet
    • Semiquantitative: vena contracta width, proximal isovelocity surface area (PISA) radius, hepatic vein flow, tricuspid inflow
    • Quantitative: Effective regurgitant orifice area (EROA), regurgitant volume, enlargement of cardiac chambers/vessels
2020 ACC/AHA Guideline for the Management of Patients with VHD38
  1. In patients with TR, TTE is indicated to:
    • evaluate the presence and severity of TR
    • determine the etiology
    • measure the sizes of the right-sided chambers and inferior vena cava
    • assess RV systolic function
    • estimate pulmonary artery systolic pressure
    • characterize any associated LSHD.

Abbreviations: 3D, Three-Dimensional; ACC, American College of Cardiology; AHA, American Heart Association; CMR, Cardiovascular Magnetic Resonance; EACTS, European Association of Cardiothoracic Surgery; EROA, Effective Regurgitant Orifice Area; ESC, European Society of Cardiology; LSHD, Left-Sided Heart Disease; PISA, Proximal Isovelocity Surface Area; RA, Right Atrium; RV, Right Ventricular; TR, Tricuspid Regurgitation; TTE, TransThoracic Echocardiography; VHD, Valvular Heart Disease.

Summary of current relevant international guidelines on the medical management of TR

2022 AHA/ACC/Heart Failure Society of America (HFSA) Guideline for the Management of Heart Failure72
  1. In patients with HF, VHD should be managed in a multidisciplinary manner in accordance with clinical practice guidelines for VHD to prevent worsening of HF and adverse clinical outcomes.
2021 ESC/EACTS Guidelines for the Management of VHD39
  1. Diuretics are useful in the presence of right HF.
  2. The addition of an aldosterone antagonist may be considered to counterbalance the activation of the renin-angiotensin-aldosterone system associated with hepatic congestion.
  3. Dedicated treatment of pulmonary HT is indicated in specific cases.
  4. Although data are limited, rhythm control may help to decrease TR and contain annular dilatation in patients with chronic AF.
  5. In the absence of advanced RV dysfunction or severe pulmonary hypertension, none of the above-mentioned therapies should delay referral for surgery or transcatheter therapy.
2021 ESC Guidelines for the Diagnosis and Treatment of Acute and Chronic HF49
  1. The management of HF with TR includes medical therapy (i.e. diuretics, neurohormonal antagonists).
2020 ACC/AHA Guideline for the Management of Patients with VHD38
  1. In patients with signs and symptoms of right-sided HF attributable to severe TR (Stages C and D), diuretics can be useful (Class 2a, Level of evidence C expert opinion).
  2. In patients with signs and symptoms of right-sided HF attributable to severe secondary TR (Stages C and D), therapies to treat the primary cause of HF (e.g. pulmonary vasodilators to reduce elevated pulmonary artery pressures, guideline-directed medical therapy (GDMT) for HF with reduced LVEF, or rhythm control of AF) can be useful (Class 2a, Level of evidence C expert opinion).

Abbreviations: ACC, American College of Cardiology; AF, Atrial Fibrillation; AHA, American Heart Association; EACTS, European Association of Cardiothoracic Surgery; ESC, European Society of Cardiology; GDMT, Guideline-Directed Medical Therapy; HF, Heart Failure; HFSA, Heart Failure Society of America; HT, Hypertension; LVEF, Left Ventricular Ejection Fraction; RV, Right Ventricular; TR, Tricuspid Regurgitation; VHD, Valvular Heart Disease.

Summary of current relevant international guidelines for surgical management of TR

2021 ESC/EACTS Guidelines for the Management of VHD39
  1. Relevant TR requires early intervention to avoid secondary damage of the RV.
  2. TR should be liberally treated at the time of left-sided valve surgery. Isolated surgery of severe secondary TR (with or without previous left-sided valve surgery) requires comprehensive assessment of the underlying disease, pulmonary hemodynamics, and RV function.
  3. Primary TR:
    • Surgery is recommended in patients with severe primary TR undergoing left-sided valve surgery (Class I, Level of evidence C)
    • Surgery is recommended in symptomatic patients with isolated severe primary TR without severe RV dysfunction (Class I, Level of evidence C)
    • Surgery should be considered in patients with moderate primary TR undergoing left-sided valve surgery (Class IIa, Level of evidence C)
    • Surgery should be considered in asymptomatic or mildly symptomatic patients with isolated severe primary TR and RV dilatation who are appropriate for surgery (Class IIa, Level of evidence C)
  4. Secondary TR:
    • Surgery is recommended in patients with severe secondary TR undergoing left-sided valve surgery (Class I, Level of evidence B)
    • Surgery should be considered in patients with mild or moderate secondary TR with a dilated annulus (≥40 mm or >21 mm/m2 by 2D echocardiography) undergoing left-sided valve surgery (Class IA, Level of evidence B)
  5. Surgery should be considered in patients with severe secondary TR (with or without previous left-sided surgery) who are symptomatic or have RV dilatation, in the absence of severe RV or left ventricular dysfunction and severe pulmonary vascular disease/hypertension (Class IIa, Level of evidence B).
2021 ESC Guidelines for the Diagnosis and Treatment of Acute and Chronic HF49
  1. Transcatheter therapy and surgery may be considered in selected cases. A multidisciplinary heart team, including HF specialists, should be considered for assessment and treatment planning.
  2. Tricuspid valve surgery is recommended in patients with severe TR requiring left-sided cardiac surgery. It should be also considered in patients with moderate TR and TA dilatation requiring left-sided cardiac surgery and in symptomatic patients with isolated severe TR.
2021 Nice Guideline [NG208] Heart Valve Disease presenting in Adults: Investigation and Management73
  1. Consider surgical tricuspid valve repair at the time of MV surgery when TR is moderate or severe.
  2. Consider surgical tricuspid valve repair at the time of aortic valve surgery when TR is severe.
2020 ACC/AHA Guideline for the Management of Patients with VHD38
  1. For patients with VHD for whom intervention is contemplated, individual risks should be calculated for specific surgical and/or transcatheter procedures, using on-line tools when available, and discussed before the procedure as a part of a shared decision-making process (Class 1, Level of evidence C expert opinion).
  2. Patients with severe VHD should be evaluated by a multidisciplinary heart valve team when intervention is considered (Class 1, Level of evidence C expert opinion).
  3. In asymptomatic patients with any type of valve intervention, a baseline postprocedural TTE followed by periodic monitoring with TTE is recommended.
  4. In patients with severe TR (Stages C and D) undergoing left-sided valve surgery, tricuspid valve surgery is recommended (Class 1, Level of evidence C limited data).

Abbreviations: ACC, American College of Cardiology; AF, atrial fibrillation; AHA, American Heart Association; EACTS, European Association of Cardiothoracic Surgery; ESC, European Society of Cardiology; HF, Heart Failure; MV, Mitral Valve; TA, Tricuspid Annulus; TR, Tricuspid Regurgitation; TTE, TransThoracic Echocardiography; VHD, Valvular Heart Disease.

Summary of current relevant international guidelines for surgical management of TR

2021 ESC/EACTS Guidelines for the Management of VHD39
  1. Transcatheter tricuspid valve intervention TTVIs are under clinical development and early registry and study data have demonstrated their feasibility to reduce TR.
  2. Transcatheter treatment of symptomatic secondary severe TR may be considered in inoperable patients at a heart valve center with expertise in the treatment of tricuspid valve disease (Class IIb, Level of evidence C).
2021 ESC Guidelines for the Diagnosis and Treatment of Acute and Chronic HF49
  1. Transcatheter therapy and surgery may be considered in selected cases. A multidisciplinary heart team, including HF specialists, should be considered for assessment and treatment planning.
  2. Transcatheter techniques have recently emerged as potential treatment options of TR. Preliminary results show improvement in TR severity and symptoms with low complication rates. Further prospective studies are needed to show the prognostic impact of these treatments in HF patients
2020 ACC/AHA Guideline for the Management of Patients with VHD38
  1. For patients with VHD for whom intervention is contemplated, individual risks should be calculated for specific surgical and/or transcatheter procedures, using on-line tools when available, and discussed before the procedure as a part of a shared decision-making process (Class 1, Level of evidence C expert opinion).

Abbreviations: ACC, American College of Cardiology; AHA, American Heart Association; EACTS, European Association of Cardiothoracic Surgery; ESC, European Society of Cardiology; HF, Heart Failure; TR, Tricuspid Regurgitation; TTVI, Transcatheter Tricuspid Valve Intervention; VHD, Valvular Heart Disease.

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