Basis for Intervention on Functional Tricuspid Regurgitation

doi:10.1053/j.semtcvs.2010.05.005

Seminars in Thoracic and Cardiovascular Surgery

Volume 22, Issue 1, Spring 2010, Pages 79-83

https://doi.org/10.1053/j.semtcvs.2010.05.005 Get rights and content

Functional tricuspid regurgitation is a complex valvular lesion. Its optimal management remains controversial in the current era as the result of uncertainties regarding accurate diagnosis, surgical indication, the appropriate surgical procedure, and the late results of surgical treatment. It is no longer regarded a benign problem and does not resolve spontaneously after correction of left-sided heart valve lesions as once believed. It carries a significant morbidity and has an adverse impact on survival. Current techniques to repair functional tricuspid regurgitation are associated with a significant degree of residual or recurrent regurgitation mainly because of failure to address all the components of this challenging entity. This review article highlights emerging concepts and advances that provide an insight into the understanding of this perplexing lesion and attempts to define the basis of intervention on functional tricuspid regurgitation.

Section snippets

Correction of Annular Dilation as the Basis for Intervention on Functional Tricuspid Regurgitation

Contrary to the traditional view, correction of left-sided valvular disease does not automatically correct functional tricuspid regurgitation.¹⁵ Treatment of the mitral lesion alone only decreases the afterload. It does not correct tricuspid dilation, nor does it affect preload or RV function.¹⁶ Dilatation of the tricuspid annulus is progressive and may not be accompanied by tricuspid regurgitation initially, but eventually leads to it.¹⁶

The normal tricuspid valve annulus is a bimodal nonplanar

Tackling of Tethering as the Basis for Intervention to Prevent Residual or Recurrent Functional Tricuspid Regurgitation

Current treatment of functional tricuspid regurgitation consists of resizing the annulus with either ring or suture annuloplasty.²⁰ Unfortunately, the success of tricuspid valve repair is often uncertain, especially with suture repair techniques, and results in residual, recurrent or progressive tricuspid regurgitation after tricuspid valve annnuloplasty.10, 11, 12, 13, 14 The presence of residual or recurrent tricuspid regurgitation is associated with increased perioperative and late

Conclusions

The management of functional tricuspid regurgitation remains a perplexing issue. However, in recent years better understanding of the pathophysiology of this complex entity has aided us in adopting a more proactive approach to deal with it. There is no question that patients with severe functional tricuspid regurgitation should have this corrected at the time of left-sided heart-valve surgery. For those with less than severe tricuspid regurgitation, the tricuspid annulus should be measured

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Cited by (47)

Application of a Series of Two-Dimensional Transesophageal Echocardiographic (2D TEE) Views Across Multiple Axes Improves the Accuracy of Tricuspid Annular Measurements
2021, Journal of Cardiothoracic and Vascular Anesthesia
Quantification of the tricuspid annulus (TA) is an important factor in determining the requirement for tricuspid annuloplasty in cardiac surgery. Three-dimensional echocardiography (3DE) has shown that the TA is biplanar with an antero-posterior longaxis and septo-lateral shortaxis, and that the commonly used 2D TEE (two-dimensional transesophageal echocardiography) four-chamber view (4ChV) underestimates the true TA longaxis. The authors hypothesized that the use of multiple 2D TEE TA views could attain greater TA long-axis measurements and smaller TA short-axis measurements than the 4ChV, and that the 4ChV has a significant but inconsistent bias relative to the maximal TA diameter measured by these views.
Prospective observational study.
Adult tertiary teaching hospital.
45 adult patients.
Multiplanar 2D TEE assessment of the tricuspid annulus.
Multiplanar assessment reliably produced larger TA long-axis measurements (93% of patients, 95% confidence interval: 81-98%) of (mean [95% confidence interval]) 40 mm (28-50 mm) compared with the 4ChV (34mm [25-44 mm], p < 0.0001) and smaller TA short-axis measurements (29 mm [20-38 mm], p < 0.0001) compared with the 4ChV. TA diameter by 4ChV assessment yielded an average bias of -5.6 mm, with 95% limits of agreement -15 to +3.9 mm compared with the largest TA long-axis measurement by multiplanar assessment.
Multiplanar 2D TEE assessment of the TA long- and short-axis consistently achieves larger and smaller measurements, respectively, than the 4ChV. The 4ChV also is not a reliable index of the TA longaxis. If the time, proficiency, or equipment required for 3DE TA assessment are unavailable, the use of multiple standard and non-standard 2D TEE TA views may offer an alternative for TA assessment.
Outcomes of Guideline-Directed Concomitant Annuloplasty for Functional Tricuspid Regurgitation
2020, Annals of Thoracic Surgery
Despite guideline recommendations, rates of concomitant tricuspid valve repair are suboptimal, possibly due to fear of complications. We reviewed morbidity, mortality, recurrent tricuspid regurgitation, and right ventricular remodeling after guideline-directed concomitant tricuspid valve repair.
We performed guideline-directed concomitant tricuspid valve repair on 171 consecutive patients who underwent left-sided valve surgery (degenerative mitral surgery or aortic valve replacement) between May 2012 and March 2016. Exclusion criteria included functional mitral regurgitation, rheumatic disease, active endocarditis, and concomitant coronary artery bypass grafting or complex aortic surgery.
Mean age was 68 ± 12 years, and 47% (81 of 171) were women. Preoperative atrial fibrillation was present in 57% (98 of 171), and preoperative tricuspid regurgitation was moderate or higher in 64% (108 of 171). The rate of de novo pacemaker placement was 4.1% (7 of 171), and the 30-day mortality rate was 0.6% (1 of 171). Estimated survival was 95% ± 4% at 1 year and 92% ± 5% at 5 years. Freedom from moderate or worse residual/recurrent tricuspid regurgitation was 93% ± 6% at 6 months and 89% ± 8% at 3 years. Quantitative echocardiography found no significant increase in right ventricular dimensions or area at 1 year in subgroup analysis. Mean echocardiographic follow-up was 14.1 months, and mean clinical follow-up was 33.9 months.
Guideline-directed concomitant tricuspid valve repair resulted in excellent safety end points and survival. At 14 months, freedom from moderate or worse tricuspid regurgitation was high, right ventricular performance did not worsen, and the pacemaker rate was comparable to rates after isolated mitral repair. Given these findings, adherence to current guidelines regarding functional tricuspid regurgitation should be encouraged.
Imaging Assessment of Tricuspid Regurgitation Severity
2019, JACC: Cardiovascular Imaging
Assessing the severity of tricuspid regurgitation remains a challenging task, and although echocardiography is the test of choice, significant limitations of the current recommendations exist. Newer methods have been used in current trials of transcatheter devices and may improve our understanding of the disease process. Cardiac magnetic resonance imaging and computed tomography angiography may play significant roles as adjunctive imaging modalities. This paper reviews the imaging modalities currently used to quantify tricuspid regurgitation severity.
Anatomy and Physiology of the Tricuspid Valve
2019, JACC: Cardiovascular Imaging
An appreciation of the complex and variable anatomy of the tricuspid valve is essential to unraveling the pathophysiology of tricuspid regurgitation. A greater appreciation of normal and abnormal anatomy is important as new methods of treating the tricuspid regurgitation are developed. This review of tricuspid valve and right heart anatomy is followed by a discussion of the possible pathophysiology of secondary (functional) tricuspid regurgitation.
Transcatheter Tricuspid Valve Interventions: Landscape, Challenges, and Future Directions
2018, Journal of the American College of Cardiology
Citation Excerpt :
In patients with lead-induced TR, coaptation devices may be prioritized, whereas TTVR could be considered for patients with intracardiac leads and extreme tricuspid annular dilation, as well as for rheumatic TR. Secondary TR has been divided into 3 stages for therapeutic purposes (76). In the early stage, initial dilation of the right ventricle leads to tricuspid annular dilation without significant leaflet tethering.
Tricuspid regurgitation is a common finding in patients with left-sided valvular or myocardial disease, often being a marker for late-stage chronic heart failure with a grim prognosis. However, isolated tricuspid valve surgery remains infrequent and is associated with the highest mortality among all valve procedures. Hence, a largely unmet clinical need exists for less invasive therapeutic options in these patients. In recent times, multiple percutaneous therapies have been developed for treating severe tricuspid regurgitation, including tricuspid valve repair and, more recently replacement, opening an entirely new venue for managing tricuspid regurgitation. The aim of this review is to provide an updated overview and a clinical perspective on novel transcatheter tricuspid valve therapies, highlighting potential challenges and future directions.
Severity of tricuspid regurgitation is associated with long-term mortality
2018, Journal of Thoracic and Cardiovascular Surgery
To determine the association between intraoperative/presurgical grade of tricuspid regurgitation (TR) and mortality, and to determine whether surgical correction of TR correlated with an increased chance of survival compared with patients with uncorrected TR.
The grade of TR assessed by intraoperative transesophageal echocardiography (TEE) before surgical intervention was reviewed for 23,685 cardiac surgery patients between 1990 and 2014. Cox proportional hazard regression models were used to determine association between grade of TR and the primary endpoint of all-cause mortality. Association between tricuspid valve (TV) surgery and survival was determined with Cox proportional hazard regression models after matching for grade of TR.
Kaplan-Meier survival curves demonstrated a relationship between all grades of TR. Multivariable analysis of the entire cohort demonstrated significantly increased mortality for moderate (hazard ratio [HR], 1.24; 95% confidence interval [CI], 1.1-1.4; P < .0001) and severe TR (HR, 2.02; 95% CI, 1.57-2.6; P < .0001). Mild TR displayed a trend for mortality (HR, 1.07; 95% CI, 0.99-1.16; P = .075). After matching for grade of TR and additional confounders, patients who underwent TV surgery had a statistically significant increased likelihood of survival (HR, 0.74; 95% CI, 0.61-0.91; P = .004).
Our study of more than 20,000 patients demonstrates that grade of TR is associated with increased risk of mortality after cardiac surgery. In addition, all patients who underwent TV surgery had a statistically significantly increased likelihood of survival compared with those with the same degree of TR who did not undergo TV surgery.

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Functional tricuspid regurgitationBasis for Intervention on Functional Tricuspid Regurgitation

Section snippets

Correction of Annular Dilation as the Basis for Intervention on Functional Tricuspid Regurgitation

Tackling of Tethering as the Basis for Intervention to Prevent Residual or Recurrent Functional Tricuspid Regurgitation

Conclusions

J Thorac Cardiovasc Surg

Int J Cardiol

Ann Thorac Surg

J Am Coll Cardiol

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

J Am Coll Cardiol

Ann Thorac Surg

Cardiovasc Surg

Am J Cardiol

J Thorac Cardiovasc Surg

Ann Thorac Surg

Surgery for tricuspid regurgitation late after mitral valve replacement

Circulation

Functional tricuspid regurgitation
Basis for Intervention on Functional Tricuspid Regurgitation