Medication Summary
The medical therapy used in the treatment of tricuspid regurgitation is directed toward the control of heart failure that is causing or contributing to the problem. Drugs used include diuretics, digoxin, and angiotensin-converting enzyme (ACE) inhibitors. Patients who have atrial fibrillation or who have received a prosthetic valve require anticoagulation.
Diuretics
Class Summary
Diuretics are used to control the fluid overload associated with tricuspid regurgitation.
Furosemide (Lasix)
Furosemide (Lasix)
Furosemide increases excretion of water by interfering with the chloride-binding cotransport system, which in turn inhibits sodium and chloride reabsorption in the ascending loop of Henle and distal renal tubule. The dose must be individualized to the patient. Depending on response, administer at increments of 20-40 mg, no sooner than 6-8 h after the previous dose, until desired diuresis occurs. When treating infants, titrate with 1 mg/kg/dose increments until a satisfactory effect is achieved.
Antidysrhythmics, V
Class Summary
These drugs (primarily digoxin) are used to control atrial fibrillation and to increase myocardial contractility.
Digoxin (Lanoxin)
Digoxin (Lanoxin, Digox)
Digoxin is a cardiac glycoside with direct inotropic effects in addition to indirect effects on the cardiovascular system. This agent acts directly on cardiac muscle, increasing myocardial systolic contractions. Its indirect actions result in increased carotid sinus nerve activity and enhanced sympathetic withdrawal for any given increase in mean arterial pressure.
Angiotensin-Converting Enzyme Inhibitors
Class Summary
ACE inhibitors are used to provide afterload reduction, thereby decreasing the volume load on the right ventricle.
Captopril
Captopril prevents conversion of angiotensin I to angiotensin II, a potent vasoconstrictor, resulting in increased levels of plasma renin and a reduction in aldosterone secretion.
Enalapril (Vasotec)
Enalapril is a competitive ACE inhibitor that reduces angiotensin II levels and decreases aldosterone secretion.
Lisinopril (Zestril, Prinivil)
Lisinopril prevents conversion of angiotensin I to angiotensin II, resulting in decreased aldosterone secretion.
Anticoagulants, Cardiovascular
Class Summary
In patients who have undergone valve replacement for treatment of severe tricuspid regurgitation, anticoagulants are used to prevent thrombosis and embolization from the prosthetic valve.
Warfarin (Coumadin, Jantoven)
Warfarin interferes with hepatic synthesis of vitamin K–dependent coagulation factors. It is used for prophylaxis and treatment of venous thrombosis, pulmonary embolism, and thromboembolic disorders. Tailor the dose to maintain an international normalized ratio (INR) in the range of 2-3.
Tables
Recommendation |
AHA/ACC (2014) [23] |
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 severe TR 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 |
