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Tricuspid Regurgitation Treatment & Management

  • Author: Mary C Mancini, MD, PhD, MMM; Chief Editor: Richard A Lange, MD, MBA  more...
 
Updated: Jun 02, 2014
 

Approach Considerations

The choice of treatment for tricuspid regurgitation depends on the etiology and severity of the condition. Medical therapy may be used in tricuspid regurgitation secondary to left-sided heart failure. With mild tricuspid regurgitation associated with mitral valve disease and pulmonary hypertension, the tricuspid regurgitation itself does not require intervention. As pulmonary vascular pressures fall with successful mitral valve therapy, the tricuspid regurgitation tends to disappear.

Surgical options include annuloplasty and valve replacement. Indications for surgical intervention include the following:

  • Structural deformity of the valve (eg, Ebstein anomaly)
  • Destruction of the valve by bacterial endocarditis
  • Severe ventricular dilatation that is uncontrolled with medical therapy
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Medical Therapy

For patients in whom tricuspid regurgitation is secondary to left-sided heart failure, treatment centers on adequate control of fluid overload and failure symptoms (eg, diuretic therapy). Patients should be instructed to reduce their intake of salt. Elevation of the head of the bed may improve symptoms of shortness of breath.

Digitalis, diuretics (including potassium-sparing agents), angiotensin-converting enzyme (ACE) inhibitors, and anticoagulants are all indicated in the care of these patients. Antiarrhythmics are added as needed to control atrial fibrillation.

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Surgical Care

Guidelines from the European Society of Cardiology and the European Association for Cardio-Thoracic Surgery (ESC/EACTS) note that the need for correction of tricuspid regurgitation is usually considered at the time of surgical correction of left-sided valve lesions.[8]

Class I ESC/EACTS indications for tricuspid valve surgery are as follows:

  • Symptomatic patients with severe tricuspid stenosis
  • Patients with severe tricuspid stenosis undergoing left-sided valve intervention
  • Patients with severe primary or secondary tricuspid regurgitation undergoing left-sided valve surgery
  • Symptomatic patients with severe isolated primary tricuspid regurgitation without severe right ventricular (RV) dysfunction

Class IIa ESC/EACTS indications for tricuspid valve surgery are as follows:

  • Patients with moderate primary tricuspid regurgitation undergoing left-sided valve surgery
  • Patients with mild or moderate secondary tricuspid regurgitation with dilated annulus undergoing left-sided valve surgery
  • Asymptomatic or mildly symptomatic patients with severe isolated primary tricuspid regurgitation and progressive RV dilatation or deterioration of RV function

The ESC/EACTS guidelines also recommend that after left-sided valve surgery, isolated tricuspid valve surgery should be considered in patients with severe tricuspid regurgitation who are symptomatic or who have progressive RV dilatation/dysfunction, provided that they do not have left-sided valve dysfunction, severe right or left ventricular dysfunction, or severe pulmonary vascular disease.

Severe regurgitation has been successfully treated with tricuspid annuloplasty. Long-term results with prosthetic rings are superior to those achieved with suture annuloplasty.[8]

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Treatment Recommendations by Etiology

In patients with organic disease of the tricuspid valve, corrective measures usually involve valve replacement. Because of the increased incidence of mechanical prosthetic valve thrombosis in this low-flow position, a bioprosthetic valve is preferable.

In patients with tricuspid valve endocarditis, total excision of the tricuspid valve without immediate replacement is recommended. The diseased valvular tissue is excised to eradicate the endocarditis, and antibiotic treatment is continued. Most patients tolerate loss of the tricuspid valve well for years. If right heart failure symptoms persist despite medical management and the infections have been controlled, an artificial valve can be inserted.

In patients with Ebstein anomaly, asymptomatic tricuspid regurgitation does not require surgery. If this anomaly produces symptomatic tricuspid regurgitation, then tricuspid valve repair or replacement is indicated.[1, 13, 14, 15, 16]

In selected cases, patients who have undergone prior tricuspid valve surgery may be candidates for percutaneous tricuspid valve replacement.[17] Indications for this procedure include significant stenosis and/or regurgitation of a bioprosthetic tricuspid valve or a right atrium–to–right ventricle (RA-to-RV) conduit.

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Further Inpatient Care

Inpatient care of patients with tricuspid regurgitation requires control of the following:

  • Heart failure
  • Treatment of any infectious process that may have affected the valve
  • Control of arrhythmias that may be present

Anticoagulation is generally in order if atrial fibrillation is present or valve replacement has been undertaken. The international normalized ratio (INR) should be maintained between 3-4 following valve replacement, because of the associated low flow state.

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Long-Term Monitoring

Patients with a history of tricuspid regurgitation should be carefully monitored for control of any heart failure. Repeat echocardiography is indicated at 6-month intervals for patients in whom the valve has been removed. Annual echocardiography should be considered in patients whose valve has been replaced.

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Contributor Information and Disclosures
Author

Mary C Mancini, MD, PhD, MMM Professor and Chief of Cardiothoracic Surgery, Department of Surgery, Louisiana State University School of Medicine in Shreveport

Mary C Mancini, MD, PhD, MMM is a member of the following medical societies: American Association for Thoracic Surgery, American College of Surgeons, American Surgical Association, Society of Thoracic Surgeons, Phi Beta Kappa

Disclosure: Nothing to disclose.

Chief Editor

Richard A Lange, MD, MBA President, Texas Tech University Health Sciences Center, Dean, Paul L Foster School of Medicine

Richard A Lange, MD, MBA is a member of the following medical societies: Alpha Omega Alpha, American College of Cardiology, American Heart Association, Association of Subspecialty Professors

Disclosure: Nothing to disclose.

Acknowledgements

Martin Gerard Keane, MD, FACC, FAHA Associate Professor, Cardiovascular Medicine Division, Department of Medicine, University of Pennsylvania School of Medicine

Martin Gerard Keane, MD, FACC, FAHA is a member of the following medical societies: Alpha Omega Alpha, American College of Cardiology, American College of Physicians, American College of Physicians-American Society of Internal Medicine, American Heart Association, American Society of Echocardiography, Pennsylvania Medical Society, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Ronald J Oudiz, MD, FACP, FACC, FCCP Professor of Medicine, University of California, Los Angeles, David Geffen School of Medicine; Director, Liu Center for Pulmonary Hypertension, Division of Cardiology, LA Biomedical Research Institute at Harbor-UCLA Medical Center

Ronald J Oudiz, MD, FACP, FACC, FCCP is a member of the following medical societies: American College of Cardiology, American College of Chest Physicians, American College of Physicians, American Heart Association, and American Thoracic Society

Disclosure: Actelion Grant/research funds Clinical Trials + honoraria; Ikaria Grant/research funds Clinical Trials + honoraria; Gilead Grant/research funds Clinical Trials + honoraria; Pfizer Grant/research funds Clinical Trials + honoraria; United Therapeutics Grant/research funds Clinical Trials + honoraria; Lilly Grant/research funds Clinical Trials + honoraria; Lung LLC Clinical Trials + honoraria; Bayer Grant/research funds Consulting; Medtronic Consulting fee Consulting; Novartis Consulting fee Consulting

Frank M Sheridan, MD Cardiologist, Providence Everett Medical Center

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

References
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