Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

primary: mild or moderate

1st line – treatment of underlying cause + follow-up

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ACUTE
|
primary: mild or moderate
1st line – 

treatment of underlying cause + follow-up

Causes of primary valve dysfunction are uncommon and include congenital aetiologies such as cleft valve in association with atrioventricular canal defect and Ebstein's anomaly; acquired aetiologies include rheumatic valvulitis, endocarditis, or scarring from carcinoid heart disease.[6]​ Less commonly, TR occurs with rheumatoid arthritis, Marfan's syndrome, pacemaker lead entrapment, and tricuspid valve prolapse, or following trauma (such as blunt force trauma or repeated endomyocardial biopsies), radiotherapy, and toxin exposure (phentermine-fenfluramine [Phen-Fen] valvulopathy or methysergide valvulopathy).

Patients with isolated mild or moderate TR are unlikely to develop symptoms of heart failure.

Patients should be followed up with clinical assessment, ECG, and echocardiogram every 6 to 12 months, urgently when symptoms develop.

Consider – heart failure management and risk factor modification

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ACUTE
|
primary: mild or moderate
Consider – 

heart failure management and risk factor modification

Additional treatment recommended for SOME patients in selected patient group

If in rare instances symptoms of heart failure do develop, medical management should include heart failure therapy with diuretics, beta-blockers, and/or vasodilating agents (e.g., ACE inhibitors and angiotensin-II receptor antagonists), and treatment of associated atrial arrhythmias for rate and rhythm control.[16][18]

In people with heart failure, lifestyle changes should include dietary and nutritional modifications, exercise training, and health maintenance.[19][20][21] Weight loss in obese patients and optimisation of blood pressure and glycaemic control are also recommended.[22] Statins or aspirin may be used in the treatment of patients with associated coronary artery disease or ischaemia.[23]

In people with concurrent atrial fibrillation, depending on further risk factors, a direct oral anticoagulant (DOAC) or warfarin is recommended for stroke prevention, while rhythm control, rate control, and lifestyle modifications are considered to manage symptoms. Aspirin is no longer recommended.[24][25]​ See Established atrial fibrillation and New-onset atrial fibrillation.

primary: severe

1st line – treatment of underlying cause + close follow-up

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ACUTE
|
primary: severe
|
asymptomatic
1st line – 

treatment of underlying cause + close follow-up

Causes of primary valve dysfunction are uncommon and include congenital aetiologies such as cleft valve in association with atrioventricular canal defect and Ebstein's anomaly; acquired aetiologies include rheumatic valvulitis, endocarditis, or scarring from carcinoid heart disease.[6]​ Less commonly, TR occurs with rheumatoid arthritis, Marfan's syndrome, pacemaker lead entrapment, and tricuspid valve prolapse, or following trauma (such as blunt force trauma or repeated endomyocardial biopsies), radiotherapy, and toxin exposure (phentermine-fenfluramine [Phen-Fen] valvulopathy or methysergide valvulopathy).

Patients with severe isolated TR may be asymptomatic. However, if followed closely most will progress to symptoms, so close medical follow-up is recommended, with referral for operation if symptoms or atrial arrhythmias develop.

Consider – heart failure management and risk factor modification

Back
ACUTE
|
primary: severe
|
asymptomatic
Consider – 

heart failure management and risk factor modification

Additional treatment recommended for SOME patients in selected patient group

Once symptoms of heart failure develop, medical management should include heart failure therapy with diuretics, beta-blockers, and/or vasodilating agents (e.g., ACE inhibitors and angiotensin-II receptor antagonists), and treatment of associated atrial arrhythmias for rate and rhythm control.[16][18]​ Failure of outpatient therapy can be an indication for intravenous inotropic agent therapy.

In people with heart failure, lifestyle changes should include dietary and nutritional modifications, exercise training, and health maintenance.[19][20][31] Weight loss in obese patients and optimisation of blood pressure and glycaemic control are also recommended.[22] Statins or aspirin may be used in the treatment of patients with associated coronary artery disease or ischaemia.[23]

In people with concurrent atrial fibrillation, depending on further risk factors, a DOAC or warfarin is recommended for stroke prevention, while rhythm control, rate control, and lifestyle modifications are considered to manage symptoms. Aspirin is no longer recommended.[24][25]​​ See Established atrial fibrillation and New-onset atrial fibrillation.

Consider – consider surgery

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ACUTE
|
primary: severe
|
asymptomatic
Consider – 

consider surgery

Additional treatment recommended for SOME patients in selected patient group

Surgery may be considered in patients who have asymptomatic severe TR with evidence of right ventricular enlargement or dysfunction.[2][5]

1st line – treatment of underlying cause

Back
ACUTE
|
primary: severe
|
symptomatic
1st line – 

treatment of underlying cause

Causes of primary valve dysfunction are uncommon and include congenital aetiologies such as cleft valve in association with AV canal defect and Ebstein's anomaly.[6]​ Rarely, isolated right heart failure may develop as a consequence of primary TR: for example, in the case of healed endocarditis. Acquired aetiologies include rheumatic valvulitis, endocarditis, or scarring from carcinoid heart disease. Less commonly, TR occurs with rheumatoid arthritis, Marfan's syndrome, pacemaker lead entrapment, and tricuspid valve prolapse, or following trauma (such as blunt force trauma or repeated endomyocardial biopsies), radiotherapy, and toxin exposure (phentermine-fenfluramine [Phen-Fen] valvulopathy or methysergide valvulopathy).

Plus – tricuspid valve replacement or annuloplasty

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ACUTE
|
primary: severe
|
symptomatic
Plus – 

tricuspid valve replacement or annuloplasty

Treatment recommended for ALL patients in selected patient group

Operation should be considered for medically refractory right heart failure, imminent or existing atrial fibrillation, or progressive right ventricular dilation and dysfunction.

Tricuspid valve replacement or annuloplasty is reasonable for severe primary TR when symptomatic.[5]

Tricuspid valve replacement is indicated in cases of 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]

Acute TR is rare and usually related to acute bacterial endocarditis. Operation includes debridement of endocarditis and repair of tricuspid valve if possible.

Repair techniques include pericardial patch repair of leaflet perforation(s), placement of artificial chordae, and annuloplasty. Valve resection and/or replacement may be indicated in selected situations.

Temporary ventricular pacing wires are recommended in all patients. Some surgeons advocate routine placement of permanent screw-in epicardial ventricular pacing leads at the time of tricuspid valve operation.[30]

Consider – heart failure management and risk factor modification

Back
ACUTE
|
primary: severe
|
symptomatic
Consider – 

heart failure management and risk factor modification

Additional treatment recommended for SOME patients in selected patient group

Medical management of heart failure includes anti-failure therapy with diuretics, beta-blockers, and/or vasodilating agents (e.g., ACE inhibitors and angiotensin-II receptor antagonists), and treatment of associated atrial arrhythmias for rate and rhythm control.[16][18]​ Failure of outpatient therapy can be an indication for intravenous inotropic agent therapy.

In people with heart failure, lifestyle changes should include dietary and nutritional modifications, exercise training, and health maintenance.[19][20][21] Weight loss in obese patients and optimisation of blood pressure and glycaemic control are also recommended.[22] Statins or aspirin may be used in the treatment of patients with associated coronary artery disease or ischaemia.[23]

In people with concurrent atrial fibrillation, depending on further risk factors, a DOAC or warfarin is recommended for stroke prevention, while rhythm control, rate control, and lifestyle modifications are considered to manage symptoms. Aspirin is no longer recommended.[24][25]​​​ See Established atrial fibrillation and New-onset atrial fibrillation.

secondary: mild or moderate

1st line – treatment of underlying cause

Back
ACUTE
|
secondary: mild or moderate
1st line – 

treatment of underlying cause

Common causes are left-sided cardiac pathology in the form of advanced mitral, aortic, and left ventricular myocardial disorders.

Treatment should address underlying cause and left-sided pathologies.

Often patients with congestive heart failure from significant left-sided heart pathology or pulmonary hypertension have moderate TR.

In moderate TR, most often the decision is whether to address secondary moderate tricuspid disease during operation for left-sided cardiac pathologies that often involve mitral or aortic valve disease.

Consider – tricuspid valve repair with annuloplasty

Back
ACUTE
|
secondary: mild or moderate
Consider – 

tricuspid valve repair with annuloplasty

Additional treatment recommended for SOME patients in selected patient group

In patients with less than severe TR who have pulmonary hypertension or tricuspid annular dilation (>40 mm or >21 mm/square metre of body surface area), tricuspid valve annuloplasty may be considered in those undergoing mitral valve surgery.[2][5][32]

Temporary ventricular pacing wires are recommended in all patients. Some surgeons advocate routine placement of permanent screw-in epicardial ventricular pacing leads at the time of tricuspid valve operation.[30]

Consider – heart failure management and risk factor modification

Back
ACUTE
|
secondary: mild or moderate
Consider – 

heart failure management and risk factor modification

Additional treatment recommended for SOME patients in selected patient group

Medical management of heart failure includes anti-failure therapy with diuretics, beta-blockers, and/or vasodilating agents (e.g., ACE inhibitors and angiotensin-II receptor antagonists), and treatment of associated atrial arrhythmias for rate and rhythm control.[16][18]​ Failure of outpatient therapy can be an indication for intravenous inotropic agent therapy.

In people with heart failure, lifestyle changes should include dietary and nutritional modifications, exercise training, and health maintenance.[19][20][21]  Weight loss in obese patients and optimisation of blood pressure and glycaemic control are also recommended.[22] Statins or aspirin may be used in the treatment of patients with associated coronary artery disease or ischaemia.[23]

In people with concurrent atrial fibrillation, depending on further risk factors, a DOAC or warfarin is recommended for stroke prevention, while rhythm control, rate control, and lifestyle modifications are considered to manage symptoms. Aspirin is no longer recommended.[24][25]​​ See Established atrial fibrillation and New-onset atrial fibrillation.

secondary: severe

1st line – treatment of underlying cause

Back
ACUTE
|
secondary: severe
1st line – 

treatment of underlying cause

Common causes are left-sided cardiac pathology in the form of advanced mitral, aortic, and left ventricular myocardial disorders.

Treatment should address the underlying cause and left-sided pathologies.

Often patients with congestive heart failure from significant left-sided heart pathology or pulmonary hypertension have moderate TR.

In severe TR, most often the decision is whether to address secondary severe tricuspid disease during operation for left-sided cardiac pathologies that often involve mitral or aortic valve disease.

Consider – heart failure management and risk factor modification

Back
ACUTE
|
secondary: severe
Consider – 

heart failure management and risk factor modification

Additional treatment recommended for SOME patients in selected patient group

Medical management of heart failure includes anti-failure therapy with diuretics, beta-blockers, and/or vasodilating agents (e.g., ACE inhibitors and angiotensin-II receptor antagonists), and treatment of associated atrial arrhythmias for rate and rhythm control.[16][18]​ Failure of outpatient therapy can be an indication for intravenous inotropic agent therapy.

In people with heart failure, lifestyle changes should include dietary and nutritional modifications, exercise training, and health maintenance.[19][20][21] Weight loss in obese patients and optimisation of blood pressure and glycaemic control are also recommended.[22] Statins or aspirin may be used in the treatment of patients with associated coronary artery disease or ischaemia.[23]

In people with concurrent atrial fibrillation, depending on further risk factors, a DOAC or warfarin is recommended for stroke prevention, while rhythm control, rate control, and lifestyle modifications are considered to manage symptoms. Aspirin is no longer recommended.[24][25]​​ See Established atrial fibrillation and New-onset atrial fibrillation.

Plus – tricuspid valve repair

Back
ACUTE
|
secondary: severe
|
with mitral valve disease requiring surgery
Plus – 

tricuspid valve repair

Treatment recommended for ALL patients in selected patient group

Tricuspid valve repair is beneficial for severe TR in patients with mitral valve disease requiring mitral valve operation.[5]

Temporary ventricular pacing wires are recommended in all patients. Some surgeons advocate routine placement of permanent screw-in epicardial ventricular pacing leads at the time of tricuspid valve operation.[30]

Plus – tricuspid valve replacement

Back
ACUTE
|
secondary: severe
|
annuloplasty or repair not possible
Plus – 

tricuspid valve replacement

Treatment recommended for ALL patients in selected patient group

Tricuspid valve replacement is reasonable for severe TR secondary to diseased/abnormal tricuspid valve leaflets not amenable to annuloplasty or repair.[5]

Temporary ventricular pacing wires are recommended in all patients. Some surgeons advocate routine placement of permanent screw-in epicardial ventricular pacing leads at the time of tricuspid valve operation.[30]

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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