Assessment of Functional Tricuspid Regurgitation

Luigi P. Badano; Denisa Muraru; Maurice Enriquez-Sarano

Disclosures

Eur Heart J. 2013;34(25):1875-1885. 

In This Article

Indications and Timing of Tricuspid Valve Surgery

In the absence of clinical trials, present guidelines are based on expert opinions. Our practice has evolved to include more surgical treatment of FTR even when it is isolated. The principles guiding surgical indications are as follows:

(A) The surgical indication for FTR is considered more actively if:

  1. another cardiac operation is considered, whether it is for valve surgery, coronary bypass, or MAZE procedure;

  2. the FTR is severe, particularly based on quantitative criteria with ERO ≥ 40 mm2;

  3. the patient is symptomatic from the TR and there are congestive signs directly related to the TR (enlarged pulsatile liver, with pulsatile jugular veins and systolic reversal in the hepatic veins by echo-Doppler). In the absence of congestive signs, marked reduction of functional capacity measured by exercise testing and without other cause than the TR is essential to consider surgery;

  4. the comorbid conditions are not overwhelming and life expectancy is of at least several years.

Thus, for example, it is reasonable to consider correction of a moderate TR without congestion if mitral valve regurgitation requires repair or to consider surgery for severe idiopathic FTR in the context of long-standing atrial fibrillation, with marked right-sided congestion. Conversely, it is less enticing to consider surgery for severe FTR with supra-systemic primary pulmonary hypertension. In any case, patients should be referred for surgery before developing secondary liver cirrhosis or severe RV dysfunction since these conditions identify a very high-risk surgical population.[47] There is increasing evidence that patients undergoing mitral valve surgery would benefit from tricuspid annuloplasty when the TA is dilated independent on the severity of TR.[6,48,49]

(B) The type of surgery performed is dependent on the morphology of the FTR:

  1. if the FTR is purely due to annular enlargement without tenting and the RV function is normal, usually annuloplasty is preferred;

  2. if tenting is the main mechanism of FTR and/or RV dysfunction may not be reversible post-operatively, annuloplasty may be associated with excess recurrence of TR[24] and either valve replacement or elongation of anterior leaflet tissue by pericardial patches may be necessary.

Table 3 summarizes the indications for the management of significant TR from the American College of Cardiology/American Heart Association (ACC/AHA)[50] and the European Society of Cardiology (ESC/EACTS).[51] Patient's clinical status, concomitant left-sided valve surgery, and the aetiology of TR usually determine the appropriate therapeutic strategy in each individual case (Figures 7 and 8).

Figure 8.

American College of Cardiology/American Heart Association50 and the European Society of Cardiology51 guideline-based algorithm for the management of tricuspid regurgitation in patients who have not previously undergone left-sided valve surgery. RV, right ventricular.

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