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

congenital

1st line – surgery + preoperative alprostadil

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ACUTE
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congenital
1st line – 

surgery + preoperative alprostadil

This represents a wide spectrum of disease that usually presents in early infancy due to cyanosis and right heart failure with ductal-dependent pulmonary blood flow (requiring continuous prostaglandin therapy to maintain ductal patency).

Infants may require single ventricle palliation (initial systemic-to-pulmonary artery shunt, second-stage hemi-Fontan or bidirectional Glenn procedure, and third-stage Fontan operation) or cardiac transplantation.

Alprostadil is given preoperatively. Infants should have frequent blood pressure checks and respiratory status should be monitored throughout treatment (e.g., continuous pulse oximetry).

Primary options

alprostadil: neonates: 0.05 to 0.1 micrograms/kg/minute intravenous infusion initially, adjust according to response, usual maintenance dose 0.01 to 0.4 micrograms/kg/minute until surgery

Plus – postoperative antiplatelet therapy

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ACUTE
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congenital
Plus – 

postoperative antiplatelet therapy

Treatment recommended for ALL patients in selected patient group

Aspirin is given postoperatively as an antiplatelet agent. The duration and choice of antiplatelet therapy varies by institution. However, the most common protocol is to continue low-dose aspirin until the shunt is either taken down surgically or allowed to thrombose over time as the patient grows.

Primary options

aspirin: neonates: 5-10 mg/kg/day orally

with carcinoid heart disease

1st line – fluid and sodium restriction + loop diuretic + somatostatin analogue + valve replacement surgery or balloon dilatation

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ACUTE
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with carcinoid heart disease
1st line – 

fluid and sodium restriction + loop diuretic + somatostatin analogue + valve replacement surgery or balloon dilatation

Fluid and sodium restriction as well as the use of diuretics treat right heart failure.

Somatostatin analogues (e.g., octreotide) have been shown to provide symptomatic improvement and improved peri-operative survival.[41]

Percutaneous balloon tricuspid dilatation is safe and effective for treating isolated severe TS in carcinoid heart disease and should be considered in those who are not operative candidates.[44]

Bioprosthetic valves are preferred and long-term results are promising.[45][46] Concomitant replacement of affected pulmonary valves may also result in less right ventricular dilatation.[47]

Tricuspid valve repair is usually not feasible as the leaflets are so restricted that residual post-repair stenosis is highly likely.

Primary options

furosemide: adults: 20-80 mg orally every 6-24 hours, maximum 600 mg/day

and

octreotide: adults: 100-600 micrograms/day subcutaneously given in 2-4 divided doses for 2 weeks, followed by 150 micrograms 3 times daily

with rheumatic fever sequelae

1st line – fluid and sodium restriction + loop diuretic

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ACUTE
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with rheumatic fever sequelae
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mild to moderate disease
1st line – 

fluid and sodium restriction + loop diuretic

Mild rheumatic tricuspid valve disease is usually asymptomatic and no specific therapy is indicated.

However, patients with more significant stenosis (or associated mitral and/or aortic valve disease) may present with symptoms of right heart failure (i.e., fatigue, dyspnoea, abdominal discomfort, and swelling).

Initial medical therapy for symptomatic patients is targeted towards relief of systemic venous congestion and includes fluid and sodium restriction and diuretics to help decrease symptoms and improve hepatic function.

Primary options

furosemide: adults: 20-80 mg orally every 6-24 hours, maximum 600 mg/day

1st line – surgical valve repair or replacement

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ACUTE
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with rheumatic fever sequelae
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severe disease
1st line – 

surgical valve repair or replacement

Severe rheumatic tricuspid valve disease is characterised by intractable right heart failure or low cardiac output that usually takes years to develop following the initial illness. In order to relieve symptoms and signs of right heart failure and diminished pulmonary blood flow due to obstruction to right ventricular inflow, surgical valve repair or replacement are the primary options.

With tricuspid valve replacement, the risk of thrombosis is significant and many clinicians advise warfarin therapy following either mechanical or bioprosthetic valve placement. Therefore, surgical repair is preferable to valve replacement whenever feasible.[40][51]​

When the annulus size and sub-valvar structures are normal, successful percutaneous balloon valvotomy has been reported.[49][50][52]​​​​​ The major adverse effect of balloon valvotomy is tricuspid regurgitation that may progress over time and ultimately require valve replacement.[32]

with infective endocarditis

1st line – appropriate antimicrobial therapy + surgery

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ACUTE
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with infective endocarditis
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absolute indications for surgery
1st line – 

appropriate antimicrobial therapy + surgery

Absolute indications for tricuspid valve surgery include persistent bacteraemia after appropriate antibiotic therapy for 1 week, right ventricular dysfunction secondary to severe tricuspid regurgitation, respiratory failure after recurrent pulmonary emboli, involvement of left-sided heart structures, large vegetations with recurrent pulmonary emboli.[2]​

Surgery typically involves a mid-line sternotomy approach, central cannulation for cardiopulmonary bypass, and tricuspid valve replacement (with a bioprosthetic or mechanical valve) in a beating or arrested heart depending on the preference of the surgeon. Many clinicians advise warfarin therapy following either mechanical or bioprosthetic valve placement.

Appropriate antimicrobial therapy according to latest treatment guidelines is initiated at the time of diagnosis, and appropriate antibiotic or antifungal therapy is determined by the sensitivity of the organisms cultured. Effective therapy generally requires 4 to 6 weeks of appropriate intravenous therapy. For certain organisms, synergy and increased efficacy may be achieved with a second antibiotic for the first 2 weeks of therapy. See Infective endocarditis.

1st line – appropriate antimicrobial therapy + surgery

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ACUTE
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with infective endocarditis
|
relative indications for surgery
1st line – 

appropriate antimicrobial therapy + surgery

Relative indications for surgery include persistent bacteraemia despite appropriate antibiotic therapy, candidal endocarditis, and large vegetations (>10 mm).

Surgery typically involves a mid-line sternotomy approach, central cannulation for cardiopulmonary bypass, and tricuspid valve replacement (with a bioprosthetic or mechanical valve) in a beating or arrested heart depending on the preference of the surgeon. Many clinicians advise warfarin therapy following either mechanical or bioprosthetic valve placement.

Appropriate antimicrobial therapy according to latest treatment guidelines is initiated at the time of diagnosis and appropriate antibiotic or antifungal therapy is determined by the sensitivity of the organisms cultured. Effective therapy generally requires 4 to 6 weeks of appropriate intravenous therapy. For certain organisms, synergy and increased efficacy may be achieved with a second antibiotic for the first 2 weeks of therapy. See Infective endocarditis.

1st line – appropriate antimicrobial therapy

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ACUTE
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with infective endocarditis
|
no indications for surgery
1st line – 

appropriate antimicrobial therapy

Infective endocarditis can affect both structurally normal and abnormal tricuspid valves.

Appropriate antimicrobial therapy according to latest treatment guidelines is initiated at the time of diagnosis, and appropriate antibiotic or antifungal therapy is determined by the sensitivity of the organisms cultured.

Effective therapy generally requires 4 to 6 weeks of appropriate intravenous therapy. For certain organisms, synergy and increased efficacy may be achieved with a second antibiotic for the first 2 weeks of therapy. See Infective endocarditis.

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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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