Tricuspid regurgitation: contemporary management of a neglected valvular lesion

Abstract

Right-sided cardiac valvular disease has traditionally been considered less clinically important than mitral or aortic valve pathology. However, detectable tricuspid regurgitation (TR) is common and recent data suggest that significant TR can lead to functional impairment and reduced survival, particularly in patients with concomitant left-sided valvular disease. The tricuspid valve is a complex anatomical structure and advances in three dimensional echocardiography and cardiac MRI have contributed to a greater understanding of tricuspid valve pathology. These imaging techniques are invaluable in determining the aetiology and severity of TR, and provide an assessment of right ventricular function and pulmonary artery pressure. TR is more prevalent in women and those with a history of myocardial infarction and heart failure. It also occurs in about 10% of patients with rheumatic heart disease. Chronic severe TR may have a prolonged clinical course culminating in the development of fatigue and poor exercise tolerance due to a reduced cardiac output. Approximately 90% of cases of TR are secondary to either pulmonary hypertension or intrinsic right ventricular pathology and about 10% are due to primary tricuspid valve disease. Primary causes such as Ebstein's anomaly, rheumatic disease, myxomatous changes, carcinoid syndrome, endomyocardial fibrosis, and degenerative disease have characteristic morphological features readily identifiable by echocardiography. Ascertaining an accurate right ventricular systolic pressure is important in separating primary from secondary causes as significant TR with a pressure <40&emsp14;mm Hg implies intrinsic valve disease. Cardiac MRI may be indicated in those with inadequate echocardiographic images and is also the gold standard for the evaluation of right ventricular function and morphology. The assessment of leaflet morphology, annular dimensions, and pulmonary artery pressure are particularly important for determining subsequent management. Along with appropriate treatment of the underlying cause of TR and pulmonary hypertension, management guidelines indicate a move towards more aggressive treatment of TR. In those undergoing left-sided valve surgery, tricuspid valve repair is universally recommended in the presence of severe coexistent TR; in those with isolated severe TR, surgery is recommended in the presence of symptoms or progressive right ventricular dilatation or dysfunction.

De Vega annuloplasty versus ring annuloplasty for repair of functional tricuspid regurgitation

“…Bernal et al believed that annuloplasty ring were more effective than De Vega procedure in preventing late TI after mitral valve repair for rheumatic heart disease. 18 Our study also demonstrated that ring annuloplasty had more efficacies in restoring and maintaining tricuspid valve function immediately after surgery and also in the long term, which indicates that ring annuloplasty is more durable method for TI repair.…”

“…18 It has been shown that ring annuloplasty remodels the annulus, decreases tension on suture lines, increases leaflet cooptation, and prevents recurrent annular dilatation, all reasons to prefer prosthetic over simple suture annuloplasty in the presence of risk factors for tricuspid repair failure, such as significant right heart dilatation and dysfunction. [17][18][19][20] If the PASP is markedly increased or the annulus moderately dilated, relatively minor leaflet disease may lead to functional TI. [19][20][21] Rheumatic heart disease (RHD) patients tend to have poor right heart function even before the occurrence of functional TI therefore the correction of even mild or moderate TI in these patients necessitates a more stable and durable annuloplasty method.…”

Implant of percutaneous tricuspid valve in patient with a previous tricuspid prosthesis: A new solution for a big problem

“…Its results are diverse depending on the series, related in part to its complex anatomy and, to a greater extent, due to its lower incidence and experience and to the change in its approach through the therapeutic strategy in recent years [1,4].…”

“…The latest studies on patients with tricuspid insufficiency secondary to left valve dysfunction, in whom surgical treatment of the tricuspid valve was not performed, show that in 60% of the cases there is no regression of the disease, which has made much more frequent the surgery on this valve affected as primary or secondary [1,4]. The perioperative mortality of this disease is high and is associated in a significant way with the patient's previous pathology, the cardiological status at the moment of the intervention, and the time of extracorporeal circulation and ischemia [2,6,11] (Figure 1).…”

Right Ventricular Endomyocardial Fibrosis (2013 Grover Conference Series)

“…42 In the presence of severe right EMF, this assessment may be hampered by the absence of gradient across the tricuspid valve, by the presence of large right atrial thrombi deviating the regurgitant jet, or by major distortion of heart anatomy. 15 In such cases, pulmonary regurgitation may be used to estimate the mean and diastolic pulmonary pressures (Fig.…”