Approach
The management of tricuspid regurgitation (TR) is guided by the underlying aetiology and pathology of the tricuspid valve. A better understanding of the negative impact of isolated tricuspid regurgitation on long-term prognosis has led to an increased role for surgical correction. In primary TR, surgery may be an option in all cases. Tricuspid valve repair or replacement is recommended for severe TR at the time of left-sided valvular surgery and in isolated severe symptomatic TR in the absence of significant right ventricular dysfunction. Surgery should be considered in all other cases (moderate TR or TR with annular enlargement at the time of left-sided valve surgery; severe TR in asymptomatic patients with evidence of right ventricular dysfunction; severe symptomatic TR after left-sided surgery in the absence of pulmonary hypertension).[2][5]
All patients with significant levels of TR (moderate or worse) or who may have pulmonary artery hypertension should be managed in conjunction with a consultant.
Medical management
The medical management of patients with tricuspid valve disease may be divided into 2 parts. The first is the treatment of the underlying cause of the tricuspid disease. The second part is the medical treatment of congestive heart failure and includes use of inotropic agents, diuretics, beta-blockers, and vasodilating agents (e.g., ACE inhibitors and angiotensin-II receptor antagonists).[16][18]
Risk factor modification
In patients with heart failure, the success of pharmacological therapy is strongly related to, and greatly enhanced by, encouraging the patient and his/her family to participate in various complementary non-pharmacological management strategies. These mainly include lifestyle changes, dietary and nutritional modifications, exercise training, and health maintenance.
Dietary sodium intake is an easily modifiable factor that complements pharmacological therapy for heart failure. Thus the patient and family are advised to follow a daily dietary sodium intake between 2 and 3 g. Further restriction to 1 to 2 g/day may be necessary for patients with advanced symptoms refractory to therapy.
Fluid restriction is mostly used as an in-hospital complementary measure in cases of acute exacerbations. In addition, fluid restriction may be warranted in cases of severe hyponatraemia. However, it would be important to advise the patient to keep a daily intake/output balance at home. Patients are advised to monitor their weight daily and to contact their healthcare provider immediately if a specified change in weight occurs.
Patients with heart failure need continuous and close monitoring of their health. A variety of programmes have been shown to decrease morbidity and rehospitalisation in this context, including home nursing, telephone advice/triage, telemedicine services, and specialised heart failure clinic-based care.[19]
Exercise training has also been shown to be beneficial.[20][21]
In addition, blood pressure and glycaemic control should be maintained at recommended targets, weight loss promoted in overweight patients, and tobacco and alcohol discontinuation recommended.[22] Statins or aspirin may be used in the treatment of patients with associated coronary artery disease or ischaemia.[23]
In people with atrial fibrillation (AF), aspirin is no longer recommended for stroke prevention, regardless of stroke risk.[24][25] Stroke prevention in AF is primarily guided by the CHA₂DS₂-VA Score, focusing on non-gender-based risk factors to estimate thromboembolic stroke risk.[24]
Anticoagulation, typically with direct oral anticoagulants or warfarin, remains the primary approach for stroke prevention in people with AF, depending on eligibility and clinical factors. For symptom management, both rate control and rhythm control strategies are considered, with the choice of approach individualised to each patient's condition. See Established atrial fibrillation and New-onset atrial fibrillation.
Indications for operative management
US and European guidelines recommendations are:[2][5]
Tricuspid valve repair is beneficial for severe TR in patients with mitral valve disease requiring mitral valve operation.
Tricuspid valve repair is reasonable for patients with severe TR undergoing left ventricular assist device implantation.
Tricuspid valve replacement or annuloplasty is reasonable for severe primary TR when symptomatic.
Tricuspid valve replacement is reasonable for severe TR secondary to diseased/abnormal tricuspid valve leaflets not amenable to annuloplasty or repair.
Tricuspid valve annuloplasty may be considered for less than severe TR in patients undergoing mitral valve surgery when there is pulmonary hypertension or tricuspid annular dilation (>40 mm or >21 mm/square metre of body surface area).
Tricuspid valve replacement or annuloplasty is not indicated in patients with mild primary TR.
Surgery may be considered in patients who have asymptomatic severe TR with evidence of right ventricular enlargement or dysfunction.
Choice of operation: valve repair versus replacement
The decision to repair or replace the tricuspid valve depends on the aetiology of the valve regurgitation, degree of leaflet and/or chordal dysfunction (i.e., tethering), and presence or significance of pulmonary hypertension.[2][5][6] Most valves are assessed with a plan towards valve repair. Indications for valve replacement over repair include severe subvalvular disease affecting leaflet mobility, severe annular dilation, right ventricular dysfunction, or pulmonary hypertension. Tricuspid valve repair has been shown to have reduced mortality rates at 1 month and 10 years when compared with valve replacement.[26][27]
Tricuspid valve repair
The most widely practised operations for tricuspid valve repair reduce the annular circumference without manipulation of the subvalvular apparatus (e.g., a morphologically normal valve). Techniques include suture bicuspidisation (Kay's annuloplasty), DeVega's annuloplasty, edge-to-edge repair, and ring (or band) annuloplasty.[28] The latter is the authors' preferred technique. All techniques recognise that the septal leaflet is intimately related to the central fibrous skeleton of the heart and, much like the intertrigonal area of the anterior mitral leaflet, is not prone to dilation; as such, the septal leaflet is not included in tricuspid annular repair. An added benefit of these repairs is that they leave a gap in the region of the atrioventricular node and its associated conduction tissue, thus avoiding complete heart block. The annuloplasty should not reduce the tricuspid valve annulus to <25 mm in diameter, as further annular reduction may lead to tricuspid valve stenosis.
Valve options for replacement
Choice of valve depends on many factors: age, severity of cardiac disease and life expectancy, concomitant use of mechanical prostheses for left-sided valve replacement, need for chronic anticoagulant therapy, sex, aetiology of TR (Ebstein's anomaly, rheumatic pathology, endocarditis), and right ventricular function have all been shown to affect morbidity and mortality of tricuspid valve replacement. The native tricuspid valve leaflet tissue is preserved as much as possible. There is no definitive consensus for which prosthesis is best with respect to tricuspid valve replacement. Prosthetic choice is left to the surgeon's clinical judgement, taking into consideration each patient's characteristics and needs.
Factors that favour using a bioprosthetic are age >65 years, short life expectancy (<5 years), operation for endocarditis, male sex, poor right ventricular function/large right atrium, and no need for anticoagulation.
Factors that favour using a mechanical prosthesis are age <65 years, longer life expectancy (>5 years), concomitant use of a left-sided mechanical valve, female sex, good right ventricular function/small right atrium, and need for chronic anticoagulation.[29]
Subsequent pacemaker therapy
Temporary ventricular pacing wires are recommended in all patients. Furthermore, some surgeons advocate routine placement of permanent screw-in epicardial ventricular pacing leads at the time of tricuspid valve operation, as permanent pacemaker lead placement across a repair is associated with failure of the repair.[30]
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