Tricuspid Regurgitation Guidelines

Updated: Nov 05, 2021
  • Author: Mary C Mancini, MD, PhD, MMM; Chief Editor: Terrence X O'Brien, MD, MS, FACC  more...
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Guidelines

Valvular Heart Disease Clinical Practice Guidelines (ACC/AHA, 2021)

The American College of Cardiology (ACC) and American Heart Association (AHA) released their updated recommendations on managing valvular heart disease in December 2020. [20, 21] Key messages include the following:

  • Patients who present with severe symptomatic isolated tricuspid regurgitation, commonly associated with device leads and AF, may benefit from surgical intervention to reduce symptoms and recurrent hospitalizations if performed before the onset of severe right ventricular dysfunction or hepatic and renal end-organ damage.

  • Bioprosthetic valve dysfunction may occur because of either degeneration of the valve leaflets or valve thrombosis. Catheter-based treatment for prosthetic valve dysfunction is reasonable in selected patients for bioprosthetic leaflet degeneration or paravalvular leak in the absence of active infection.

Go to 2021 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy for full details.

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Management of VHD Clinical Practice Guidelines (ESC/EACTS, 2021)

Guidelines for the management of patients with valvular heart disease (VHD) were published in August 2021 by the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS) in European Journal of Cardiothoracic Surgery. [22]

Surgery is recommended for patients with severe primary tricuspid regurgitation undergoing left-side valve surgery and for symptomatic patients with isolated severe primary tricuspid regurgitation without severe right ventricular (RV) dysfunction.

Surgery is recommended for patients with severe secondary tricuspid regurgitation undergoing left-side valve surgery.

Go to 2021 ESC/EACTS Guidelines for the management of valvular heart disease for full details.

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Guidelines for the Management of Valvular Heart Disease (ACC/AHA, 2012 and ESC/EACTS, 2014)

In 2014, the AHA/ACC released a revision to its 2008 guidelines for management of patients with valvular heart disease (VHD) [23] ; and ESC/EACTS issued a revision of its 2007 guidelines in 2012. [8]

The AHA/ACC guidelines classify progression of tricuspid regurgitation (TR) into 4 stages (A to D) as follows [23] :

  • Stage A: At Risk of TR
  • Stage B: Progressive TR
  • Stage C: Asymptomatic with severe TR
  • Stage D: Symptomatic with severe TR

Both guidelines require intervention decisions for severe valvular heart disease (VHD) should be based on an individual risk-benefit analysis. Improved prognosis should outweigh the risk of intervention and potential late consequences, particularly complications related to prosthetic valves. [8, 23]

Recognizing the known limitations of the EuroSCORE (European System for Cardiac Operative Risk Evaluation) and the STS (Society of Thoracic Surgeons) score, the AHA/ACC guidelines suggest using STS plus three additional indicators: frailty (using accepted indices), major organ system compromise not to be improved postoperatively, and procedure-specific impediment when assessing risk. [23]

Diagnosis

The AHA/ACC guidelines include the following recommendations for diagnostic testing and initial diagnosis of TR [23] :

  • Transthoracic echocardiography (TTE) for the initial evaluation of patients to evaluate severity of TR, determine etiology, measure sizes of right-sided chambers and inferior vena cava, assess RV systolic function, estimate pulmonary artery systolic pressure, and characterize any associated left-sided heart disease. (Class I; Level of evidence: C)
  • Invasive measurement of pulmonary artery pressures and pulmonary vascular resistance can be useful when clinical and noninvasive data are discordant.(Class IIa; Level of evidence: C)
  • Consider CMR or real-time 3-dimensional echocardiography for assessment of RV systolic function and systolic and diastolic volumes in patients with severe TR (stages C and D) and suboptimal 2-dimensional echocardiograms. (Class IIb; Level of evidence: C)
  • Consider exercise testing to assess exercise capacity in patients with severe TR with no or minimal symptoms (stage C). (Class IIb; Level of evidence: C)

Surgical Indications

A comparison of the recommendations for surgical intervention is provided in the table below.

Table. Comparison of Recommendations for tricuspid valve disease Intervention (Open Table in a new window)

Recommendation

AHA/ACC (2014) [23]

ESC/EACTS (2012) [8]

Tricuspid valve surgery for patients with severe tricuspid regurgitation(TR) or severe tricuspid stenosis (TS) when undergoing left-sided valve surgery

Class I

Class I

Tricuspid valve surgery for patients with isolated, symptomatic severe TS.

Class I

Class I

Tricuspid valve surgery for patients with isolated, symptomatic severe TR without severe right ventricle dysfunction

 

Class I

Tricuspid valve repair for patients with mild, moderate, or greater functional TR (stage B) at the time of left-sided valve surgery with either 1) tricuspid annular dilation or 2) prior evidence of right HF

Class IIa-Reasonable

Class IIa-Reasonable

Tricuspid valve surgery for patients with symptoms due to severe primary TR that are unresponsive to medical therapy (stage D).

Class IIa-Reasonable

 

After left-sided valve surgery, surgery for patients with severe TR who are symptomatic or have progressive right ventricular dilatation/dysfunction, in the absence of left-sided valve dysfunction,

severe right or left ventricular dysfunction, and severe pulmonary vascular disease

 

Class IIa-Reasonable

Tricuspid valve repair for patients with moderate functional TR (stage B) and pulmonary artery hypertension at the time of left-sided valve surgery

Class IIb-Consider

 

Tricuspid valve surgery for asymptomatic or minimally symptomatic patients with severe primary TR (stage C) and progressive degrees of moderate or greater RV dilation and/or systolic dysfunction.

Class IIb-Consider

Class IIa-Reasonable

Reoperation for isolated tricuspid valve repair or replacement for persistent symptoms due to severe TR (stage D) in patients who have undergone previous left-sided valve surgery and who do not have severe pulmonary hypertension or significant RV systolic dysfunction.

Class IIb-Consider

 

Percutaneous balloon tricuspid commissurotomy in patients with isolated, symptomatic severe TS without accompanying TR.

Class IIb-Consider

 

 

For more Clinical Practice Guidelines, please go to Guidelines.

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