Tricuspid Regurgitation Guidelines

Updated: Nov 28, 2018
  • Author: Mary C Mancini, MD, PhD, MMM; Chief Editor: Terrence X O'Brien, MD, MS, FACC  more...
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Guidelines

Guidelines Summary

In 2014, the AHA/ACC released a revision to its 2008 guidelines for management of patients with valvular heart disease (VHD) [20] ; and ESC/EACTS issued a revision of its 2007 guidelines in 2012. [8]

The AHA/ACC guidelines classify progression of tricuspid regurgitation (TR)  into 4 stages (A to D) as follows [20] :

  • Stage A: At Risk of TR
  • Stage B: Progressive TR
  • Stage C: Asymptomatic with severe TR
  • Stage D: Symptomatic with severe TR

Both guidelines require intervention decisions for severe valvular heart disease (VHD) should be based on an individual risk-benefit analysis. Improved prognosis should outweigh the risk of intervention and potential late consequences, particularly complications related to prosthetic valves. [8, 20]

Recognizing the known limitations of the EuroSCORE (European System for  Cardiac Operative Risk Evaluation) and the STS (Society of Thoracic Surgeons) score , the AHA/ACC guidelines suggest using STS plus three additional indicators: frailty (using accepted indices), major organ system compromise not to be improved postoperatively, and procedure-specific impediment when assessing risk. [20]

Diagnosis

The AHA/ACC guidelines include the following recommendations for diagnostic testing and initial diagnosis of TR [20] :

  • Transthoracic echocardiography (TTE) for the initial evaluation of patients to evaluate severity of TR, determine etiology, measure sizes of right-sided chambers and inferior vena cava, assess RV systolic function, estimate pulmonary artery systolic pressure, and characterize any associated left-sided heart disease. (Class I; Level of evidence:C)
  • Invasive measurement of pulmonary artery pressures and pulmonary vascular resistance can be useful when clinical and noninvasive data are discordant. (Class IIa; Level of evidence: C)
  • Consider CMR or real-time 3-dimensional echocardiography for assessment of RV systolic function and systolic and diastolic volumes in patients with severe TR (stages C and D) and suboptimal 2-dimensional echocardiograms. (Class IIb; Level of evidence: C)
  • Consider exercise testing to assess exercise capacity in patients with severe TR with no or minimal symptoms (stage C).  (Class IIb; Level of evidence: C) 

Surgical Indications

A comparison of the recommendations for surgical intervention is provided in the table below.

Table. Comparison of Recommendations for tricuspid valve disease Intervention (Open Table in a new window)

Recommendation

AHA/ACC (2014) [20]

ESC/EACTS (2012) [8]

Tricuspid valve surgery for patients with severe tricuspid regurgitation(TR) or severe tricuspid stenosis (TS) when undergoing left-sided valve surgery

Class I

Class I

Tricuspid valve surgery for patients with isolated, symptomatic severe TS.

Class I

Class I

Tricuspid valve surgery for patients with isolated, symptomatic severeTR without severe right ventricle dysfunction

 

Class I

Tricuspid valve repair for patients with mild, moderate, or greater functional TR (stage B) at the time of left-sided valve surgery with either 1) tricuspid annular dilation or 2) prior evidence of right HF

Class IIa-Reasonable

Class IIa-Reasonable

Tricuspid valve surgery for patients with symptoms due to severe primary TR that are unresponsive to medical therapy (stage D).

Class IIa-Reasonable

 

After left-sided valve surgery, surgery for patients with severe TR who are symptomatic or have progressive right ventricular dilatation/dysfunction, in the absence of left-sided valve dysfunction,

severe right or left ventricular dysfunction, and severe pulmonary vascular disease

 

Class IIa-Reasonable

Tricuspid valve repair for patients with moderate functional TR (stage B) and pulmonary artery hypertension at the time of left-sided valve surgery

Class IIb-Consider

 

Tricuspid valve surgery for asymptomatic or minimally symptomatic patients with severe primary TR (stage C) and progressive degrees of moderate or greater RV dilation and/or systolic dysfunction.

Class IIb-Consider

Class IIa-Reasonable

Reoperation for isolated tricuspid valve repair or replacement for persistent symptoms due to severe TR (stage D) in patients who have undergone previous left-sided valve surgery and who do not have severe pulmonary hypertension or significant RV systolic dysfunction.

Class IIb-Consider

 

Percutaneous balloon tricuspid commissurotomy in patients with isolated, symptomatic severe TS without accompanying TR.

Class IIb-Consider