Management of tricuspid valve regurgitation

Abstract

Tricuspid regurgitation (TR) is a very frequent manifestation of valvular heart disease. It may be due to the primary involvement of the valve or secondary to pulmonary hypertension or to the left-sided heart valve disease (most commonly rheumatic and involving the mitral valve). The pathophysiology of secondary TR is complex and is intrinsically connected to the anatomy and function of the right ventricle. A systematic multimodality approach to diagnosis and assessment (based not only on the severity of the TR but also on the assessment of annular size, RV function and degree of pulmonary hypertension) is, therefore, essential. Once considered non-important, treatment of secondary TR is currently viewed as an essential concomitant procedure at the time of mitral (and, less frequently, aortic valve) surgery. Although the indications for surgical management of severe TR are now generally accepted (Class I), controversy persists concerning the role of intervention for moderate TR. However, there is a trend for intervention in this setting, especially at the time of surgery for left-sided heart valve disease and/or in patients with significant tricuspid annular dilatation (Class IIa). Currently, surgery remains the best approach for the interventional treatment of TR. Percutaneous tricuspid valve intervention (both repair and replacement) is still in its infancy but may become a reliable option in future, especially for high-risk patients with isolated primary TR or with secondary TR related to advanced left-sided heart valve disease.

First-in-Human Transcatheter Tricuspid Valve Repair in a Patient With Severely Regurgitant Tricuspid Valve

“…Interest in the tricuspid valve has increased in recent years (13)(14)(15) with the recognition of the impact of secondary tricuspid regurgitation on outcomes (1,2,5,7,16,17) and the benefits of tricuspid repair (6,18). TR is an independent predictor of long-term mortality (2,7).…”

“…The prevalence of secondary TR with mitral valve disease is >30% (13,14), with some studies suggesting that more than 1.6 million patients in the United States may have this disease (19).…”

Tricuspid regurgitation and the right ventricle in risk stratification and timing of intervention

“…The relationship of the RV with TR is complex. Treatment options are governed by the underlying aetiology (Table 2) and hence an understanding of the mechanisms for TR is essential (53) (Fig. 4).…”

“…Both late residual TR seen post mitral valve surgery (3) and isolated severe TR (4) have excess mortality and morbidity. Management guidelines remain ill defined since prospective outcome data are limited (5). Further, surgical TV intervention studies have suggested variable outcomes and this conflicting data have led to confusion as to optimal management in this cohort.…”

Assessment of tricuspid valve by two‐ and three‐dimensional echocardiography with special reference to percutaneous repair and prosthetic valve implantation procedures

“…24 The TV apparatus can be divided into several components: the fibrous annulus, anterior leaflet (AL), septal leaflet (SL) and posterior/inferior leaflet (PL/IL), anterior and posterior papillary muscles, and the chordal attachments. 21,[25][26][27][28][29] The annular plane of the TV is nearly vertical and approximately 45° from the sagittal plane. The 3 TV leaflets vary in circumferential and radial size; the AL being the longest radial leaflet with the largest area and greatest motion.…”