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:
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Structural deformity of the valve (eg, Ebstein anomaly)
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Destruction of the valve by bacterial endocarditis
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Severe ventricular dilatation that is uncontrolled with medical therapy
In a recent study, investigators evaluated a novel transcatheter repair system for the treatment of severe tricuspid regurgitation. They treated seven high-risk patients with severe tricuspid regurgitation and clinical signs of heart failure, who were declined for surgery, with the transcatheter repair system. All patients showed improvements in the severity of tricuspid regurgitation, as well as improvements in peripheral edema and functional status. [13]
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.
Surgical Care
The need for correction of tricuspid regurgitation is usually considered at the time of surgical correction of left-sided valve lesions. Severe regurgitation has been successfully treated with tricuspid annuloplasty. Long-term results with prosthetic rings are superior to those achieved with suture annuloplasty. [8]
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, 14, 15, 16, 17]
Ibrahim et al found evidence that cone reconstruction of severe tricuspid valve regurgitation associated with Ebstein’s anomaly provides effective repair. In their analysis of 27 consecutive cone reconstructions undertaken from 2009 to 2013, they found that patients’ clinical status improved with better left ventricle filling and objective exercise capacity. [18]
In selected cases, patients who have undergone prior tricuspid valve surgery may be candidates for percutaneous tricuspid valve replacement. [19] 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.
Further Inpatient Care
Inpatient care of patients with tricuspid regurgitation requires control of the following:
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Heart failure
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Treatment of any infectious process that may have affected the valve
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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.
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.
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 |
