Tricuspid regurgitation surgery: Difference between revisions

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__NOTOC__
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{{Tricuspid regurgitation}}
{{Tricuspid regurgitation}}
{{CMG}}; {{AE}} {{Rim}} {{FB}}
{{CMG}}; {{AE}} {{Sara.Zand}} {{Rim}} {{FB}}
{{SK}} TR; Tricuspid regurgitation; Primary TR; Secondary TR; AF; Atrial fibrillation; RV; Right ventricle, TTE; Transthoracic echocardiography


==Overview==
==Overview==
The main therapy is treatment of the underlying cause. In most cases, surgery is not indicated since the root problem lies with a dilated or damaged [[right ventricle]]. When surgical treatment is done, it is usually done as part of another procedure, most commonly [[mitral valve repair]] for [[mitral regurgitation]].
[[Pulmonary hypertension]] or [[myocardial]] [[disease]] are two factors that affect the treatment of [[secondary TR]]. The surgical approach is considered for selected [[patients]] with severe [[TR]] (stage C,D) at the time of [[left-sided valve lesions]] [[surgery]] and to prevent later development of severe [[TR]] in [[patients]] with progressive [[TR ]] (Stage B). For selected [[patients]] with isolated [[TR]] (either [[primary TR ]] or [[secondary TR]] attributable to [[annular dilation]] in the absence of [[pulmonary hypertension]] or [[dilated cardiomyopathy]]), [[surgical intervention]] is recommended. [[Mortality rate]] is high in [[patients]] undergone interventions for severe isolated [[TR]] due to [[end-organ damage]]. However, outcomes of [[patients]] with severe [[primary TR]] are poor with medical management. Earlier surgery for [[patients]] with severe isolated [[TR]] before the onset of severe [[RV dysfunction]] or [[end-organ damage]] is recommended.


==Surgery==
==Surgery==
===Surgical Methods===
===Indications for Surgery===
'''Principal surgical technique:''' The principal surgical repair for secondary TR is tricuspid annuloplasty. The aim of tricuspid annuloplasty is to improve leaflet coaptation by correcting annular dilatation and restoring annular geometry. The two principle surgical methods are:<ref name="pmidPMID: 27048553">{{cite journal| author=Rodés-Cabau J, Taramasso M, O'Gara PT| title=Diagnosis and treatment of tricuspid valve disease: current and future perspectives. | journal=Lancet | year= 2016 | volume= 388 | issue= 10058 | pages= 2431-2442 | pmid=PMID: 27048553 | doi=10.1016/S0140-6736(16)00740-6 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27048553  }} </ref><ref name="pmid22340261">{{cite journal| author=Taramasso M, Vanermen H, Maisano F, Guidotti A, La Canna G, Alfieri O| title=The growing clinical importance of secondary tricuspid regurgitation. | journal=J Am Coll Cardiol | year= 2012 | volume= 59 | issue= 8 | pages= 703-10 | pmid=22340261 | doi=10.1016/j.jacc.2011.09.069 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22340261  }} </ref>  
* Primary or secondary severe [[TR]] may not improve after treatment of the left-sided [[valve]] lesion and reduction of [[RV afterload]]. <ref name="pmid33332150">{{cite journal |vauthors=Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C |title=2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines |journal=Circulation |volume=143 |issue=5 |pages=e72–e227 |date=February 2021 |pmid=33332150 |doi=10.1161/CIR.0000000000000923 |url=}}</ref>
* '''Ring annuloplasty''': It is regarded as the standard for surgical repair. The size of the tricuspid annulus is permanently fixed by implantation of a rigid or semirigid prosthetic, undersized ring, and it is associated with a reduced incidence of late, recurrent tricuspid regurgitation.
*Re-operation for severe, isolated [[TR]] after left-sided [[valve]] surgery is associated with a [[perioperative]] [[mortality rate]] of 10% to 25%.
* '''Suture annuloplasty''': It is technically easy and can be done quickly. Also, compared with ring annuloplasty, a prosthetic implant is not used with suture annuloplasty and the risk of postoperative conduction disturbances is lower.
* [[Tricuspid valv]]e repair will not increase the risks of [[surgery]].<ref name="pmid19470900">{{cite journal |vauthors=Rogers JH, Bolling SF |title=The tricuspid valve: current perspective and evolving management of tricuspid regurgitation |journal=Circulation |volume=119 |issue=20 |pages=2718–25 |date=May 2009 |pmid=19470900 |doi=10.1161/CIRCULATIONAHA.108.842773 |url=}}</ref>
'''Other methods:'''<ref name="pmidPMID: 27048553" />
* [[Tricuspid valve]] repair is preferable to replacement due to lower operative risk, but replacement may be indicated if there is marked dilation of the annulus or intrinsic disease of the [[tricuspid]] leaflets.<ref name="pmid20813324">{{cite journal |vauthors=Chikwe J, Anyanwu AC |title=Surgical strategies for functional tricuspid regurgitation |journal=Semin Thorac Cardiovasc Surg |volume=22 |issue=1 |pages=90–6 |date=2010 |pmid=20813324 |doi=10.1053/j.semtcvs.2010.05.002 |url=}}</ref>
* '''Adjunctive repair techniques:''' This may be necessary for augmentation of the effects of ring annuloplasty in patients with marked leaflet tethering and right ventricular remodeling. The long-term outcomes and durability of these adjunctive techniques are not well established. Types of adjunctive repair techniques are listed in the table below.
* The risks and benefits of [[tricuspid valve]] operation should be carefully considered in the presence of severe [[RV systolic dysfunction]] or irreversible [[pulmonary hypertension]] because of the possibility of [[RV failure]] after the operation.
{| class="wikitable sortable"
*If mild or moderate degrees of [[secondary TR]] are left uncorrected at the time of left-sided valve surgery, they may progress over time in approximately 25% of [[patients]] and result in reduced long-term functional outcome and [[survival]].
|+
*Risk factors for persistence or progression of [[TR]] include [[tricuspid annulus dilation]] (>40 mm diameter or 21 mm/m2 diameter indexed to [[body surface area]] on preoperative [[TTE]] measured at [[end-diastole]]; >70 mm diameter on direct intraoperative measurement of the intercomissural distance), degree of [[RV dysfunction]] or remodeling, leaflet tethering height, [[pulmonary artery hypertension]], [[AF]], and intra-annular [[RV pacemaker]] or [[implantable cardioverter-defibrillator]] leads.
!Anterior leaflet augmentation using autologous pericardial patch
* Studies showed the benefits of [[tricuspid repair]] at the time of [[mitral]] valve [[surgery]] for [[progressive TR]] (Stage B) with [[tricuspid]] annulus dilation.
!“Clover” technique
!Double orifice valve technique
*In [[patients]] with symptomatic severe [[primary TR]], reduction of the [[regurgitant]] [[volume]] load by [[tricuspid valve]] surgery can decrease [[systemic venous]] and [[hepatic]] congestion and the need for [[diuretics]].
|-
* [[Patients]] with severe congestive [[hepatopathy]] may also benefit from [[surgery]] to prevent irreversible [[cirrhosis]] of the [[liver]].
|Helps improve leaflet coaptation while maintaining leaflet mobility
* Quality and duration of long-term survival are related to residual [[RV function]].<ref name="pmid31422359">{{cite journal |vauthors=Kadri AN, Menon V, Sammour YM, Gajulapalli RD, Meenakshisundaram C, Nusairat L, Mohananey D, Hernandez AV, Navia J, Krishnaswamy A, Griffin B, Rodriguez L, Harb SC, Kapadia S |title=Outcomes of patients with severe tricuspid regurgitation and congestive heart failure |journal=Heart |volume=105 |issue=23 |pages=1813–1817 |date=December 2019 |pmid=31422359 |doi=10.1136/heartjnl-2019-315004 |url=}}</ref>
|
* In [[patients]] with severe symptomatic [[primary TR]] from either device leads or [[endomyocardial biopsy]], [[TR]] develops rapidly, and [[surgery]] can be performed before the onset of [[RV dysfunction]].
* Approximates the free edges of the three leaflets, producing a clover-shaped valve
* Correction of symptomatic severe [[primary TR ]] (Stage D) in [[patients]] without left-sided valve disease would preferentially be performed before the onset of significant [[RV dysfunction]] or [[end-organ damage]]
* It has also been used to treat selected patients with complex primary tricuspid regurgitation
*[[ TR ]] can develop in attribution with [[AF]] and [[annular dilation]] (a form of [[secondary TR]]).<ref name="pmid11163563">{{cite journal |vauthors=Mangoni AA, DiSalvo TG, Vlahakes GJ, Polanczyk CA, Fifer MA |title=Outcome following isolated tricuspid valve replacement |journal=Eur J Cardiothorac Surg |volume=19 |issue=1 |pages=68–73 |date=January 2001 |pmid=11163563 |doi=10.1016/s1010-7940(00)00598-4 |url=}}</ref>
|
* [[AF]]-related [[TR]] may represent greater basal dilation and annular enlargement. However, [[RV elongation]] with leaflet tethering is seen in [[patients]] who have [[secondary TR]] caused by [[pulmonary hypertension]] or [[myocardial disease]].
* Promising outcomes have been reported
* These [[patients]] with [[AF]]-related [[TR]] have rapid progression of [[TR]] severity and right-sided chamber [[dilation]].  
* Done by passing two sutures from the middle of the anterior portion of the annulus to the septal portion of the annulus, forcing leaflet coaptation
* In [[ AF]]-related severe [[TR]], [[quality of life]] and [[symptoms]] can be improved by [[surgical]] intervention for [[TR]].
|}
* Outcomes are better in [[patients]] undergoing intervention and no evidence of severe [[RV dysfunction]] or [[end-organ damage]].
* '''Tricuspid valve replacement''': Should be undertaken when valve repair is not technically feasible or predictably durable. Valve repair should be considered as a first option in patients with secondary tricuspid regurgitation and marked right ventricular remodeling and leaflet tethering, and in patients with complex primary tricuspid regurgitation or severe tricuspid stenosis. Bioprosthetic valves are currently favored, however, no differences in survival or adverse events at long-term follow-up have been recorded in patients receiving mechanical or biological valves.
 
* '''Transcatheter therapies''': The safety and feasibility of transcatheter therapies for treating severe tricuspid regurgitation are still being investigated. Three types of transcatheter therapies have recently emerged for treating severe tricuspid regurgitation:
# Heterotopic caval transcatheter valve implantation
# Transcatheter tricuspid valve annuloplasty
# Coaptation device
* '''Transcatheter tricuspid valve replacement''': This has been done in experimental studies in ewes, it has not been done in humans.<ref name="pmidPMID: 16022968">{{cite journal| author=Boudjemline Y, Agnoletti G, Bonnet D, Behr L, Borenstein N, Sidi D et al.| title=Steps toward the percutaneous replacement of atrioventricular valves an experimental study. | journal=J Am Coll Cardiol | year= 2005 | volume= 46 | issue= 2 | pages= 360-5 | pmid=PMID: 16022968 | doi=10.1016/j.jacc.2005.01.063 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16022968  }} </ref>


===Indications for Surgery===
Shown below is an algorithm depicting the indications for tricuspid valve surgery adapted from the 2014 AHA/ACC guideline for the management of patients with valvular heart disease. If the patient does not meet any of the decision pathways in the algorithm, regular monitoring with medical therapy is recommended and surgery is not indicated.<ref name="pmid24589852">{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume=  | issue=  | pages=  | pmid=24589852 | doi=10.1161/CIR.0000000000000029 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24589852  }} </ref>


{{Family tree/start}}
{{Family tree | | | | | | | | | | | A01 | | | | | | | | | | | | | | | A01= Determine the stage of the tricuspid regurgitation (TR)}}
{{Family tree | | | |,|-|-|-|-|-|-|-|+|-|-|-|-|-|-|-|-|.| | | | | | | }}
{{Family tree | | | B01 | | | | | | B02 | | | | | | | B03 | | | | | | B01= Progressive functional <br> ''[[Tricuspid regurgitation stages|(Stage B)]]''| B02= Asymptomatic severe <br> ''[[Tricuspid regurgitation stages|(Stage C)]]''| B03= Symptomatic severe <br> ''[[Tricuspid regurgitation stages|(Stage D)]]''}}
{{Family tree | | | |!| | | | | | | |!| | | | | | | | |!| | | | | | | }}
{{Family tree | | | C01 | | | | | | C02 | | | | | | | C03 | | | | | | C01= Is TR mild or moderate? | C02= What is the underlying cause of TR?| C03= Has the TR been previously operated on?}}
{{Family tree | | | |!| | | | | | | |!| | | | | |,|-|-|^|-|-|.| | | | }}
{{Family tree | | | |!| | | | | | | |!| | | | | D01 | | | | D02 | | | D01= Yes| D02= No}}
{{Family tree | | | |!| | | | | | | |!| | | | | |!| | | | | |!| | | | }}
{{Family tree | | | |!| | | | | | | |!| | | | | |!| | | | | E01 | | | E01= What is the underlying cause of TR?}}
{{Family tree | | |,|^|.| | | | |,|-|^|-|.| | | |!| | | |,|-|^|-|.| | }}
{{Family tree | F01 | | F02 | | F03 | | F04 | | |!| | | F05 | | F06 | F01= Mild| F02= Moderate| F03= Functional| F04= Primary| F05=Functional| F06= Primary}}
{{Family tree | | |!| |!| | | | |!| | | |!| | | |!| | | |!| | | |!| | }}
{{Family tree | | | G01 | | | | G02 | | G03 | | G04 | | G05 | | G06 | G01= The patient is undergoing left-sided valve surgery| G02= The patient is undergoing left-sided valve surgery| G03= The patient is experiencing progressive [[right ventricular dysfunction]] <br>AND/OR<br>systolic dysfunction | G04= The patient has persistent symptoms <br> AND <br> The patient has preserved right ventricular function and the [[pulmonary hypertension]] is not severe| G05= The patient is undergoing left-sided valve surgery | G06= The patient is unresponsive to medical therapy}}
{{Family tree | |,|-|^|-|.| | | |!| | | | |!| |!| | | | |!| | | |!| | }}
{{Family tree | I01 | | I02 | | |!| | | | |!| |!| | | | |!| | | |!| | I01= The patient has tricuspid annular dilatation <br> OR <br> Prior evidence of [[right heart failure]]| I02= The patient has pulmonary hypertension without tricuspid annular dilatation}}
{{Family tree | |!| | | |!| | | |!| | | | |!| |!| | | | |!| | | |!| | }}
{{Family tree | J01 | | J02 | | J03 | | | | J04 | | | | J05 | | J06 | J01= Tricuspid valve repair <br> ([[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]])| J02= Tricuspid valve repair <br> ([[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]])| J03= Tricuspid valve repair or replacement<br> ([[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]])| J04= Tricuspid valve repair or replacement<br> ([[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]])| J05= Tricuspid valve repair or replacement<br> ([[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]])| J06= Tricuspid valve repair or replacement<br> ([[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]])}}
{{Family tree/end}}


{| class="wikitable"
! colspan="3" | '''ESC and EACTS Guideline for Management (2012)'''
!Primary TR
!Class of recommendation
!Level of evidence
|-
|Severe TR at the time of left-sided valve surgery
|I
|C
|-
|Severe symptomatic isolated TR without severe right ventricular dysfunction
|I
|C
|-
|Moderate TR at the time of left-sided valve surgery
|IIa
|C
|-
|Asymptomatic or mildly symptomatic isolated severe TR and progressive right ventricular dilatation or deterioration of right ventricular function
|IIa
|C
|-
| colspan="3" |                                                                              '''Secondary TR'''
|-
|Severe TR at the time of left-sided valve surgery
|I
|C
|-
|Mild or moderate TR with dilated annulus (≥40 mm or >21 mm/m²) at the time of left-sided valve surgery
|IIa
|C
|-
|Severe TR late after left-sided valve surgery with symptoms or progressive right ventricular dilatation or dysfunction, in the absence of left-sided valve dysfunction, severe right or left ventricular dysfunction, and severe pulmonary vascular disease
|IIa
|C
|}


'''Class of recommendation''':
* I: benefi t>>>risk; procedure should be done; usefulness or efficacy established.
* IIa: benefi t>>risk; additional studies with focused objectives required; it is reasonable to do procedure; evidence favours usefulness or efficacy
* IIb: benefi t>risk; additional studies with broad objectives needed; procedure may be considered; usefulness or efficacy less well established.


'''Level of evidence''':
* B: limited populations evaluated; data derived from a single randomised trial or non-randomised studies.
* C: very limited populations studied; only consensus opinion of experts, case studies, standard of care.
AHA=American Heart Association. ACC=American College of Cardiology. TR=tricuspid regurgitation. ESC=European Society of Cardiology. EACTS=European Association of Cardiothoracic Surgery


==2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary<ref name="pmid24589852">{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume=  | issue=  | pages=  | pmid=24589852 | doi=10.1161/CIR.0000000000000029 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24589852  }} </ref>==


{|class="wikitable"
{| style="cellpadding=0; cellspacing= 0; width: 800px;"
|-
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for intervention in tricuspid valve disease'''
|-
|-
| bgcolor="lightgreen" |<nowiki>"</nowiki>'''1.''' Tricuspid valve surgery is recommended for patients with severe [[TR]] (stages C and D) undergoing left-sided valve surgery.  ([[ACC AHA guidelines classification scheme#Level of Evidence|''Level of Evidence: C'']])<nowiki>"</nowiki>
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' Primary Tricuspid Regurgitation ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|}
 
{|class="wikitable"
|-
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Surgery]] is recommended in [[patients]] with severe primary [[tricuspid regurgitation]] undergoing left-sided valve surgery<br>
❑[[Surgery]] is recommended in [[symptomatic]] [[patients]] with isolated severe primary [[tricuspid regurgitation]] without severe [[RV dysfunction]]<br>


|-
|-
| bgcolor="lemonchiffon" |<nowiki>"</nowiki>'''1.''' Tricuspid valve repair can be beneficial for patients with mild, moderate, or greater functional [[TR]] (stage B) at the time of left-sided valve surgery with either:
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' Primary Tricuspid Regurgitation ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
* Tricuspid annular dilation or
* Prior evidence of right heart failure.  ([[ACC AHA guidelines classification scheme#Level of Evidence|''Level of Evidence: B'']])<nowiki>"</nowiki>
|-
|-
| bgcolor="lemonchiffon" |<nowiki>"</nowiki>'''2.''' Tricuspid valve surgery can be beneficial for patients with symptoms due to severe primary [[TR]] that are unresponsive to medical therapy (stage D).  ([[ACC AHA guidelines classification scheme#Level of Evidence|''Level of Evidence: C'']])<nowiki>"</nowiki>
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
|}
❑[[Surgery]] should be considered in [[patients]] with moderate primary [[tricuspid regurgitation]] undergoing [[left-sided valve]] [[surgery]]<br>
 
❑[[Surgery]] should be considered in asymptomatic or mildly symptomatic [[patients]] with isolated severe primary [[tricuspid regurgitation]] and [[RV dilatation]] who are appropriate for [[surgery]]<br>
{|class="wikitable"
|-
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''  Secondary Tricuspid Regurgitation ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|-
| bgcolor="lemonchiffon" |<nowiki>"</nowiki>'''1.''' Tricuspid valve repair may be considered for patients with moderate functional [[TR]] (stage B) and pulmonary artery hypertension at the time of left-sided valve surgery.  ([[ACC AHA guidelines classification scheme#Level of Evidence|''Level of Evidence: C'']])<nowiki>"</nowiki>
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Surgery]] is recommended in [[patients]] with severe secondary [[tricuspid regurgitation]] undergoing left-sided valve surgery<br>
|-
|-
| bgcolor="lemonchiffon" |<nowiki>"</nowiki>'''2.''' Tricuspid valve surgery may be considered 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.  ([[ACC AHA guidelines classification scheme#Level of Evidence|''Level of Evidence: C'']])<nowiki>"</nowiki>
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''  Secondary Tricuspid Regurgitation ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
| bgcolor="lemonchiffon" |<nowiki>"</nowiki>'''3.''' Reoperation for isolated tricuspid valve repair or replacement may be considered 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. ([[ACC AHA guidelines classification scheme#Level of Evidence|''Level of Evidence: C'']])<nowiki>"</nowiki>
|}
 
==2008 and Incorporated 2006 ACC/AHA Guidelines for the Management of Patients with Valvular Heart Disease (DO NOT EDIT) <ref name="pmid18820172">{{cite journal |author=Bonow RO, Carabello BA, Chatterjee K, ''et al.'' |title=2008 Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons |journal=Circulation |volume=118 |issue=15 |pages=e523–661 |year=2008 |month=October |pmid=18820172 |doi=10.1161/CIRCULATIONAHA.108.190748 |url=}}</ref>==
 
===Tricuspid Valve Replacement (DO NOT EDIT) <ref name="pmid18820172">{{cite journal |author=Bonow RO, Carabello BA, Chatterjee K, ''et al.'' |title=2008 Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons |journal=Circulation |volume=118 |issue=15 |pages=e523–661 |year=2008 |month=October |pmid=18820172 |doi=10.1161/CIRCULATIONAHA.108.190748 |url=}}</ref>===
 
{|class="wikitable"
|-
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Surgery]] should be considered in [[patients]] with mild or moderate secondary [[tricuspid regurgitation]] with a dilated [[annulus]] (≥40 mm or >21 mm/m2 by 2D [[echocardiography]]) undergoing
left-sided valve [[surgery]]<br>
❑[[Surgery]] should be considered in [[patients]] with severe secondary [[tricuspid regurgitation]] (with or without previous left-sided [[surgery]]) who are
symptomatic or have [[RV]] dilatation, in the absence of severe [[RV]] or [[LV dysfunction]] and severe [[pulmonary vascular disease]]/ [[pulmonary hypertension]]<br>
|-
|-
| bgcolor="lightgreen" |<nowiki>"</nowiki>'''1.''' Tricuspid valve repair is beneficial for severe [[TR]] in patients with [[mitral valve disease]] requiring [[mitral valve surgery]]. ([[ACC AHA guidelines classification scheme#Level of Evidence|''Level of Evidence: B'']])<nowiki>"</nowiki>
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' Secondary Tricuspid Regurgitation ([[ ESC guidelines classification scheme|Class IIb, Level of Evidence C]]):'''
|}
 
{|class="wikitable"
|-
|-
| colspan="1" style="text-align:center; background:LightCoral"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]]
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Transcatheter]] treatment of symptomatic secondary severe [[tricuspid regurgitation ]] may be considered in inoperable [[patients]]<br>


|-
|
| bgcolor="lightcoral" |<nowiki>"</nowiki>'''1.''' Tricuspid valve replacement or [[annuloplasty]] is not indicated in asymptomatic patients with [[TR]] whose pulmonary artery systolic                                          pressure is less than 60 mm Hg in the presence of a normal [[mitral valve]]. ([[ACC AHA guidelines classification scheme#Level of Evidence|''Level of Evidence: C'']])<nowiki>"</nowiki>
|}
|-
{|
| bgcolor="lightcoral" |<nowiki>"</nowiki>'''2.''' Tricuspid valve replacement or [[annuloplasty]] is not indicated in patients with mild primary [[TR]].  ([[ACC AHA guidelines classification scheme#Level of Evidence|''Level of Evidence: C'']])<nowiki>"</nowiki>
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}
|}


{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]


|-
{{familytree/start}}
| bgcolor="lemonchiffon" |<nowiki>"</nowiki>'''1.''' Tricuspid valve replacement or [[annuloplasty]] is reasonable for severe primary [[TR]] when symptomatic. ([[ACC AHA guidelines classification scheme#Level of Evidence|''Level of Evidence: C'']])<nowiki>"</nowiki>
{{familytree | | | | | | | | | B01 | | | | | |B01=[[Tricuspid regurgitation]]}}
|-
{{familytree | | |,|-|-|-|-|-|-|^|-|-|-|-|-|-|.| }}
| bgcolor="lemonchiffon" |<nowiki>"</nowiki>'''2.''' Tricuspid valve replacement is reasonable for severe [[TR]] secondary to diseased/abnormal tricuspid valve leaflets not amenable                                          to [[annuloplasty]] or repair. ([[ACC AHA guidelines classification scheme#Level of Evidence|''Level of Evidence: C'']])<nowiki>"</nowiki>
{{familytree | | C01 | | | | | | | | | | | | |!| C01=Progressive [[TR]] (Stage B)| }}
|}
{{familytree | | |!| | | | | | | | | | | | | |!| }}
{{familytree | | D01 | | | | | | | | | | | |D02|D01=At time of left sided [[valve]] [[surgery]]|D02=Severe [[TR]] (Stage C,D)}}
{{familytree | | |!| | | | | | | | | |,|-|-|-|+|-|-|-|-|.|}}
{{familytree | | E01 | | | | | | | | E02 | | E03 | | | E04 |E01=Annular dilation> 4 cm, or perior righ [[heart failure]] |E02=[[Asymptomatic]] (Stage C)|E03=At time of left sided [[valve]] [[surgery]]|E04=[[Right heart failure]] (Stage D)}}
{{familytree | | |!| | | | | | | | | |!| | | |!| | | | |!| | }}
{{familytree | |  K | | | | | | | | | F01 | | F02 | | |!|F01= [[Primary TR]] with progressive [[RV]] dilation or [[systolic]] dysfunction |F02=[[TV]] [[surgery]] (1)|K=[[TV]] [[surgery]] (2a)}}
{{familytree | | | | | | | | | | | | |!| | | | | | | | |!| | | | | | | | | | | | | |}}
{{familytree | | | | | | | | | | | |  E1 | | | | | | | |!| | | | | | | | | | | | | E1=[[TV]] [[surgery]] (2b)| |}}
{{familytree | | | | | | | | | | | | | | | | | | | | | |!| | | | | | | | | | | | | |}}
{{familytree | | | | | | | | | | | | | | | | | |,|-|-|-|+|-|-|-|.| | | | | | | | | |}}
{{familytree | | | | | | | | | | | | | | | | | N1| | | N2| | N3| | | | | | | | | | N1=[[Primary TR]]|N2=Prior [[left sided]] valve [[surgery]]|N3=[[Secondary TR]]}}
{{familytree | | | | | | | | | | | | | | | | | |!| | | |!| | | |!| | | | | | | | | |}}
{{familytree | | | | | | | | | | | | | | | | |L1 | | |G2 | |U1 | | | | | | | | | | |L1=[[TV]] [[surgery]] (2a)|G2=Absent of severe [[pulmonary hypertension]] or [[RV systolic dysfunction]] |U1=Poor response to [[medical therapy]] |}}
{{familytree | | | | | | | | | | | | | | | | | | | | | |!| | | |!| | | | | | | | | |}}
{{familytree | | | | | | | | | | | | | | | | | | | | |G3 | | | U2| | | | | | | | | | |G3=[[TV]] [[surgery]] (2b) |U2=Annular dilation without [[pulmonary hypertension]] or left sided [[disease]]|}}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | |!| | | | | | | | | | | | |}}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | U3| | | | | | | | | | | |U3=[[TV]] [[surgery]] (2a) |}}
{{familytree/end}}
<span style="font-size:85%">'''Abbreviations:'''
'''TR:''' [[Tricuspid Regurgitation]];
'''TV:''' [[Tricuspid valve]];
'''RV:''' [[Right ventricle]]
</span>
<br>


{|class="wikitable"
{|
|-
! colspan="2" style="background: PapayaWhip;" align="center" + |The above algorithm adapted from 2020 AHA Guideline<ref name="pmid33332149">{{cite journal |vauthors=Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C |title=2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines |journal=Circulation |volume=143 |issue=5 |pages=e35–e71 |date=February 2021 |pmid=33332149 |doi=10.1161/CIR.0000000000000932 |url=}}</ref>
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
|-
| bgcolor="lemonchiffon" |<nowiki>"</nowiki>'''1.''' Tricuspid valve replacement or [[annuloplasty]] is reasonable for severe primary [[TR]] when symptomatic. ([[ACC AHA guidelines classification scheme#Level of Evidence|''Level of Evidence: C'']])<nowiki>"</nowiki>
|}
|}


===Surgical Methods===
====Annuloplasty====
The principal surgical repair for secondary TR is [[tricuspid]] [[annuloplasty]]. The aim of tricuspid [[annuloplasty]] is to improve leaflet coaptation by correcting annular dilatation and restoring annular geometry. The two principle surgical methods are:<ref name="pmidPMID: 27048553">{{cite journal| author=Rodés-Cabau J, Taramasso M, O'Gara PT| title=Diagnosis and treatment of tricuspid valve disease: current and future perspectives. | journal=Lancet | year= 2016 | volume= 388 | issue= 10058 | pages= 2431-2442 | pmid=PMID: 27048553 | doi=10.1016/S0140-6736(16)00740-6 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27048553  }} </ref><ref name="pmid22340261">{{cite journal| author=Taramasso M, Vanermen H, Maisano F, Guidotti A, La Canna G, Alfieri O| title=The growing clinical importance of secondary tricuspid regurgitation. | journal=J Am Coll Cardiol | year= 2012 | volume= 59 | issue= 8 | pages= 703-10 | pmid=22340261 | doi=10.1016/j.jacc.2011.09.069 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22340261  }} </ref>
* '''Ring annuloplasty''': It is regarded as the standard for surgical repair. The size of the [[tricuspid]] annulus is permanently fixed by implantation of a rigid or semi rigid [[prosthesis]], undersized ring, and it is associated with a reduced incidence of late, recurrent [[tricuspid regurgitation]].
* '''Suture annuloplasty''': It is technically easy and can be done quickly. Also, compared with the ring [[annuloplasty]], a [[Prosthesis|prosthetic]] implant is not used with [[suture]] [[annuloplasty]] and the risk of postoperative conduction disturbances is lower.


[[File:Leaflet coaptation.jpg|alt=leaflet coaptation|center|thumb|600x600px|The transthoracic echocardiography after tricuspid valve repair showed satisfactory leaflet coaptation (A) and repaired papillary muscle (B). Case courtesy by Han-Young Jin et al <ref>{{Cite web|url=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3079085/|title=A Case of Traumatic Tricuspid Regurgitation Caused by Multiple Papillary Muscle Rupture|last=|first=|date=|website=|archive-url=|archive-date=|dead-url=|access-date=}}</ref>]]


===Indications for Intervention Adolescents (DO NOT EDIT) <ref name="pmid18820172">{{cite journal |author=Bonow RO, Carabello BA, Chatterjee K, ''et al.'' |title=2008 Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons |journal=Circulation |volume=118 |issue=15 |pages=e523–661 |year=2008 |month=October |pmid=18820172 |doi=10.1161/CIRCULATIONAHA.108.190748 |url=}}</ref>===


{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="lightgreen" |<nowiki>"</nowiki>'''1.''' Surgery for severe [[TR]] is recommended for adolescent and young adult patients with deteriorating exercise capacity ([[NYHA]] functional                                          class III or IV). ([[ACC AHA guidelines classification scheme#Level of Evidence|''Level of Evidence: C'']])<nowiki>"</nowiki>
|-
| bgcolor="lightgreen" |<nowiki>"</nowiki>'''2.''' Surgery for severe [[TR]] is recommended for adolescent and young adult patients with progressive [[cyanosis]] and [[arterial oxygen saturation|arterial saturation]]                                          less than 80% at rest or with exercise. ([[ACC AHA guidelines classification scheme#Level of Evidence|''Level of Evidence: C'']])<nowiki>"</nowiki>
|-
| bgcolor="lightgreen" |<nowiki>"</nowiki>'''3.''' [[cardiac catheterization|Interventional catheterization]] closure of the atrial communication is recommended for the adolescent or young adult with [[TR]]                                          who is [[hypoxemic]] at rest and with exercise intolerance due to increasing [[hypoxemia]] with exercise, when the [[tricuspid valve]]                                          appears difficult to repair surgically. ([[ACC AHA guidelines classification scheme#Level of Evidence|''Level of Evidence: C'']])<nowiki>"</nowiki>
|}


{|class="wikitable"
'''Other methods:'''<ref name="pmidPMID: 27048553" />
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]


* '''Adjunctive repair techniques:''' This may be necessary for augmentation of the effects of the ring [[annuloplasty]] in patients with marked leaflet tethering and [[Right ventricle|right ventricular]] remodeling. The long-term outcomes and durability of these adjunctive techniques are not well established. Types of adjunctive repair techniques are listed in the table below.
{| class="wikitable"
!Anterior leaflet augmentation using an autologous pericardial patch
!<nowiki>''Clover''</nowiki> technique
!Double orifice valve technique
|-
|-
| bgcolor="lemonchiffon" |<nowiki>"</nowiki>'''1.''' Surgery for severe [[TR]] is reasonable in adolescent and young adult patients with [[NYHA]] functional class II symptoms if the [[tricuspid valve|valve]]                                         appears to be repairable. ([[ACC AHA guidelines classification scheme#Level of Evidence|''Level of Evidence: C'']])<nowiki>"</nowiki>
|Helps improve leaflet coaptation while maintaining leaflet mobility
|-
|
| bgcolor="lemonchiffon" |<nowiki>"</nowiki>'''2.''' Surgery for severe [[TR]] is reasonable in adolescent and young adult patients with [[atrial fibrillation]]. ([[ACC AHA guidelines classification scheme#Level of Evidence|''Level of Evidence: C'']])<nowiki>"</nowiki>
* Approximates the free edges of the three leaflets, producing a clover-shaped valve
* It has also been used to treat selected patients with complex primary [[tricuspid regurgitation]]
|
* Promising outcomes have been reported
* Done by passing two sutures from the middle of the anterior portion of the annulus to the septal portion of the annulus, forcing leaflet coaptation
|}
|}
* '''Tricuspid valve replacement'''
*The initial approach in [[tricuspid]] surgery is repair; however, replacement is done whenever the valve is badly diseased.
**[[Bioprosthetic valves]] are currently favored, however, no significant hemodynamic difference between mechanical and [[biological valves]] was observed.<ref name="pmid24757625">{{cite journal |vauthors=Altaani HA, Jaber S |title=Tricuspid Valve Replacement, Mechnical vs. Biological Valve, Which Is Better? |journal=Int Cardiovasc Res J |volume=7 |issue=2 |pages=71–4 |date=June 2013 |pmid=24757625 |pmc=3987430 |doi= |url=}}</ref>
* '''Transcatheter therapies'''
**The safety and feasibility of transcatheter therapies for treating severe [[tricuspid regurgitation]] are shown in the study:
**Three types of transcatheter therapies have recently emerged for treating severe tricuspid regurgitation:
**#Heterotopic caval transcatheter valve [[implantation]]
**#Transcatheter [[tricuspid valve]] [[annuloplasty]]
**#Coaptation device


{|class="wikitable"
* '''Transcatheter tricuspid valve replacement'''<ref name="pmid33419880">{{cite journal |vauthors=Lu FL, An Z, Ma Y, Song ZG, Cai CL, Li BL, Zhou GW, Han L, Wang J, Bai YF, Liu XH, Wang JF, Meng X, Zhang HB, Yang J, Dong NG, Hu SS, Pan XB, Cheung A, Qiao F, Xu ZY |title=Transcatheter tricuspid valve replacement in patients with severe tricuspid regurgitation |journal=Heart |volume=107 |issue=20 |pages=1664–1670 |date=October 2021 |pmid=33419880 |doi=10.1136/heartjnl-2020-318199 |url=}}</ref>
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
| bgcolor="lemonchiffon" |<nowiki>"</nowiki>'''1.''' Surgery for severe [[TR]] may be considered in asymptomatic adolescent and young adult patients with increasing heart size and                                          a [[cardiothoracic ratio]] of more than 65%. ([[ACC AHA guidelines classification scheme#Level of Evidence|''Level of Evidence: C'']])<nowiki>"</nowiki>
|-
| bgcolor="lemonchiffon" |<nowiki>"</nowiki>'''2.''' Surgery for severe [[TR]] may be considered in asymptomatic adolescent and young adult patients with stable heart size and an                                          [[arterial oxygen saturation|arterial saturation]] of less than 85% when the [[tricuspid valve]] appears repairable. ([[ACC AHA guidelines classification scheme#Level of Evidence|''Level of Evidence: C'']])<nowiki>"</nowiki>
|-
| bgcolor="lemonchiffon" |<nowiki>"</nowiki>'''3.''' In adolescent and young adult patients with [[TR]] who are mildly [[cyanotic]] at rest but who become very [[hypoxemic]] with exercise,                                          closure of the atrial communication by [[cardiac catheterization|interventional catheterization]] may be considered when the valve does not appear amenable                                          to repair. ([[ACC AHA guidelines classification scheme#Level of Evidence|''Level of Evidence: C'']])<nowiki>"</nowiki>
|-
| bgcolor="lemonchiffon" |<nowiki>"</nowiki>'''4.''' If surgery for [[Ebstein’s anomaly]] is planned in adolescents and young adult patients (tricuspid valve repair or replacement),                                          a preoperative electrophysiological study may be considered to identify accessory pathways. If present, these may be considered                                          for mapping and ablation either preoperatively or at the time of surgery.  ([[ACC AHA guidelines classification scheme#Level of Evidence|''Level of Evidence: C'']])<nowiki>"</nowiki>
|}


=== Tricuspid Valve Surgery (DO NOT EDIT) <ref name="pmid18820172">{{cite journal |author=Bonow RO, Carabello BA, Chatterjee K, ''et al.'' |title=2008 Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons |journal=Circulation |volume=118 |issue=15 |pages=e523–661 |year=2008 |month=October |pmid=18820172 |doi=10.1161/CIRCULATIONAHA.108.190748 |url=}}</ref>===
== 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines<ref name="pmid333321502">{{cite journal| author=Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F | display-authors=etal| title=2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. | journal=Circulation | year= 2021 | volume= 143 | issue= 5 | pages= e72-e227 | pmid=33332150 | doi=10.1161/CIR.0000000000000923 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33332150  }}</ref> ==


{|class="wikitable"
=== Recommendations for Timing of Intervention Referenced studies that support the recommendations are summarized in the Online Data Supplement ===
{| class="wikitable"
|-
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
| colspan="1" style="text-align:center; background:LightGreen" |[[ESC guidelines classification scheme#Classification of Recommendations|Class I]]  
|-
|-
| bgcolor="lightgreen" |<nowiki>"</nowiki>'''1.''' Severe [[TR]] in the setting of surgery for multivalvular disease should be corrected. ([[ACC AHA guidelines classification scheme#Level of Evidence|''Level of Evidence: C'']])<nowiki>"</nowiki>
| bgcolor="LightGreen" |1.   In patients with severe TR (Stages C and D) undergoing left-sided valve surgery, tricuspid valve surgery is recommended. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR]])''
|}
|}
 
{| class="wikitable"
{|class="wikitable"
|-
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ESC guidelines classification scheme#Classification of Recommendations|Class IIa]]
 
|-
|-
| bgcolor="lemonchiffon" |<nowiki>"</nowiki>'''1.''' Tricuspid annuloplasty is reasonable for mild [[TR]] in patients undergoing [[MV surgery]] when there is [[pulmonary hypertension]]                                or tricuspid annular dilatation. ([[ACC AHA guidelines classification scheme#Level of Evidence|''Level of Evidence: C'']])<nowiki>"</nowiki>
| bgcolor="LemonChiffon" |2.   In patients with progressive TR (Stage B) undergoing left-sided valve surgery, tricuspid valve surgery can be beneficial in the context of either 1) tricuspid annular dilation (tricuspid annulus end diastolic diameter >4.0 cm) or 2) prior signs and symptoms of right-sided HF.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR]])''
3.   In patients with signs and symptoms of right-sided HF and severe primary TR (Stage D), isolated tricuspid valve surgery can be beneficial to reduce symptoms and recurrent hospitalizations''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR]])''
4.   In patients with signs and symptoms of right-sided HF and severe isolated secondary TR attributable to annular dilation (in the absence of pulmonary hypertension or left-sided disease) who are poorly responsive to medical therapy (Stage D), isolated tricuspid valve surgery can be beneficial to reduce symptoms and recurrent hospitalizations.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR]])''
|}
|}
 
{| class="wikitable"
===Intraoperative Assessment (DO NOT EDIT) <ref name="pmid18820172">{{cite journal |author=Bonow RO, Carabello BA, Chatterjee K, ''et al.'' |title=2008 Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons |journal=Circulation |volume=118 |issue=15 |pages=e523–661 |year=2008 |month=October |pmid=18820172 |doi=10.1161/CIRCULATIONAHA.108.190748 |url=}}</ref>===
 
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
|-
| bgcolor="lightgreen" |<nowiki>"</nowiki>'''1.''' Intraoperative [[transesophageal echocardiography]] is recommended for valve repair surgery. ([[ACC AHA guidelines classification scheme#Level of Evidence|''Level of Evidence: B'']])<nowiki>"</nowiki>
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ESC guidelines classification scheme#Classification of Recommendations|Class IIb]]
 
|-
|-
| bgcolor="lightgreen" |<nowiki>"</nowiki>'''2.''' Intraoperative [[transesophageal echocardiography]] is recommended for [[valve replacement surgery]] with a stentless [[xenograft]], [[homograft]],                                    or [[autograft]] valve.([[ACC AHA guidelines classification scheme#Level of Evidence|''Level of Evidence: B'']])<nowiki>"</nowiki>
| bgcolor="LemonChiffon" |5.   In asymptomatic patients with severe primary TR (Stage C) and progressive RV dilation or systolic dysfunction, isolated tricuspid valve surgery may be considered''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-LD)]]''
6.   In patients with signs and symptoms of right-sided HF and severe TR (Stage D) who have undergone previous left-sided valve surgery, reoperation with isolated tricuspid valve surgery may be considered in the absence of severe pulmonary hypertension or severe RV systolic dysfunction''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR]])''
|}
|}


{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
| bgcolor="lemonchiffon" |<nowiki>"</nowiki>'''1.''' Intraoperative [[transesophageal echocardiography]] is reasonable for all patients undergoing cardiac valve surgery. ([[ACC AHA guidelines classification scheme#Level of Evidence|''Level of Evidence: C'']])<nowiki>"</nowiki>
|}


==Sources==
*2008 ACC/AHA Guidelines incorporated into the 2006 guidelines for the management of patients with valvular heart disease <ref name="pmid18820172">{{cite journal |author=Bonow RO, Carabello BA, Chatterjee K, ''et al.'' |title=2008 Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons |journal=Circulation |volume=118 |issue=15 |pages=e523–661 |year=2008 |month=October |pmid=18820172 |doi=10.1161/CIRCULATIONAHA.108.190748 |url=}}</ref>


==References==
==References==

Latest revision as of 15:11, 8 December 2022

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sara Zand, M.D.[2] Rim Halaby, M.D. [3] Fatimo Biobaku M.B.B.S [4] Synonyms and keywords: TR; Tricuspid regurgitation; Primary TR; Secondary TR; AF; Atrial fibrillation; RV; Right ventricle, TTE; Transthoracic echocardiography

Overview

Pulmonary hypertension or myocardial disease are two factors that affect the treatment of secondary TR. The surgical approach is considered for selected patients with severe TR (stage C,D) at the time of left-sided valve lesions surgery and to prevent later development of severe TR in patients with progressive TR (Stage B). For selected patients with isolated TR (either primary TR or secondary TR attributable to annular dilation in the absence of pulmonary hypertension or dilated cardiomyopathy), surgical intervention is recommended. Mortality rate is high in patients undergone interventions for severe isolated TR due to end-organ damage. However, outcomes of patients with severe primary TR are poor with medical management. Earlier surgery for patients with severe isolated TR before the onset of severe RV dysfunction or end-organ damage is recommended.

Surgery

Indications for Surgery





Recommendations for intervention in tricuspid valve disease
Primary Tricuspid Regurgitation (Class I, Level of Evidence C):

❑Surgery is recommended in patients with severe primary tricuspid regurgitation undergoing left-sided valve surgery
❑Surgery is recommended in symptomatic patients with isolated severe primary tricuspid regurgitation without severe RV dysfunction

Primary Tricuspid Regurgitation (Class IIa, Level of Evidence C):

❑Surgery should be considered in patients with moderate primary tricuspid regurgitation undergoing left-sided valve surgery
❑Surgery should be considered in asymptomatic or mildly symptomatic patients with isolated severe primary tricuspid regurgitation and RV dilatation who are appropriate for surgery

Secondary Tricuspid Regurgitation (Class I, Level of Evidence B):

❑Surgery is recommended in patients with severe secondary tricuspid regurgitation undergoing left-sided valve surgery

Secondary Tricuspid Regurgitation (Class IIa, Level of Evidence B):

❑Surgery should be considered in patients with mild or moderate secondary tricuspid regurgitation with a dilated annulus (≥40 mm or >21 mm/m2 by 2D echocardiography) undergoing left-sided valve surgery
❑Surgery should be considered in patients with severe secondary tricuspid regurgitation (with or without previous left-sided surgery) who are symptomatic or have RV dilatation, in the absence of severe RV or LV dysfunction and severe pulmonary vascular disease/ pulmonary hypertension

Secondary Tricuspid Regurgitation (Class IIb, Level of Evidence C):

❑Transcatheter treatment of symptomatic secondary severe tricuspid regurgitation may be considered in inoperable patients
The above table adopted from 2021 ESC Guideline[6]


 
 
 
 
 
 
 
 
Tricuspid regurgitation
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Progressive TR (Stage B)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
At time of left sided valve surgery
 
 
 
 
 
 
 
 
 
 
 
Severe TR (Stage C,D)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Annular dilation> 4 cm, or perior righ heart failure
 
 
 
 
 
 
 
Asymptomatic (Stage C)
 
At time of left sided valve surgery
 
 
Right heart failure (Stage D)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
TV surgery (2a)
 
 
 
 
 
 
 
 
Primary TR with progressive RV dilation or systolic dysfunction
 
TV surgery (1)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
TV surgery (2b)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Primary TR
 
 
Prior left sided valve surgery
 
Secondary TR
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
TV surgery (2a)
 
 
Absent of severe pulmonary hypertension or RV systolic dysfunction
 
Poor response to medical therapy
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
TV surgery (2b)
 
 
Annular dilation without pulmonary hypertension or left sided disease
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
TV surgery (2a)
 
 
 
 
 
 
 
 
 
 
 

Abbreviations: TR: Tricuspid Regurgitation; TV: Tricuspid valve; RV: Right ventricle

The above algorithm adapted from 2020 AHA Guideline[7]

Surgical Methods

Annuloplasty

The principal surgical repair for secondary TR is tricuspid annuloplasty. The aim of tricuspid annuloplasty is to improve leaflet coaptation by correcting annular dilatation and restoring annular geometry. The two principle surgical methods are:[8][9]

  • Ring annuloplasty: It is regarded as the standard for surgical repair. The size of the tricuspid annulus is permanently fixed by implantation of a rigid or semi rigid prosthesis, undersized ring, and it is associated with a reduced incidence of late, recurrent tricuspid regurgitation.
  • Suture annuloplasty: It is technically easy and can be done quickly. Also, compared with the ring annuloplasty, a prosthetic implant is not used with suture annuloplasty and the risk of postoperative conduction disturbances is lower.
leaflet coaptation
The transthoracic echocardiography after tricuspid valve repair showed satisfactory leaflet coaptation (A) and repaired papillary muscle (B). Case courtesy by Han-Young Jin et al [10]


Other methods:[8]

  • Adjunctive repair techniques: This may be necessary for augmentation of the effects of the ring annuloplasty in patients with marked leaflet tethering and right ventricular remodeling. The long-term outcomes and durability of these adjunctive techniques are not well established. Types of adjunctive repair techniques are listed in the table below.
Anterior leaflet augmentation using an autologous pericardial patch ''Clover'' technique Double orifice valve technique
Helps improve leaflet coaptation while maintaining leaflet mobility
  • Approximates the free edges of the three leaflets, producing a clover-shaped valve
  • It has also been used to treat selected patients with complex primary tricuspid regurgitation
  • Promising outcomes have been reported
  • Done by passing two sutures from the middle of the anterior portion of the annulus to the septal portion of the annulus, forcing leaflet coaptation
  • Tricuspid valve replacement
  • The initial approach in tricuspid surgery is repair; however, replacement is done whenever the valve is badly diseased.
  • Transcatheter therapies
    • The safety and feasibility of transcatheter therapies for treating severe tricuspid regurgitation are shown in the study:
    • Three types of transcatheter therapies have recently emerged for treating severe tricuspid regurgitation:
      1. Heterotopic caval transcatheter valve implantation
      2. Transcatheter tricuspid valve annuloplasty
      3. Coaptation device
  • Transcatheter tricuspid valve replacement[12]

2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines[13]

Recommendations for Timing of Intervention Referenced studies that support the recommendations are summarized in the Online Data Supplement

Class I
1.   In patients with severe TR (Stages C and D) undergoing left-sided valve surgery, tricuspid valve surgery is recommended. (Level of Evidence: B-NR)
Class IIa
2.   In patients with progressive TR (Stage B) undergoing left-sided valve surgery, tricuspid valve surgery can be beneficial in the context of either 1) tricuspid annular dilation (tricuspid annulus end diastolic diameter >4.0 cm) or 2) prior signs and symptoms of right-sided HF.(Level of Evidence: B-NR)

3.   In patients with signs and symptoms of right-sided HF and severe primary TR (Stage D), isolated tricuspid valve surgery can be beneficial to reduce symptoms and recurrent hospitalizations(Level of Evidence: B-NR) 4.   In patients with signs and symptoms of right-sided HF and severe isolated secondary TR attributable to annular dilation (in the absence of pulmonary hypertension or left-sided disease) who are poorly responsive to medical therapy (Stage D), isolated tricuspid valve surgery can be beneficial to reduce symptoms and recurrent hospitalizations.(Level of Evidence: B-NR)

Class IIb
5.   In asymptomatic patients with severe primary TR (Stage C) and progressive RV dilation or systolic dysfunction, isolated tricuspid valve surgery may be considered(Level of Evidence: C-LD)

6.   In patients with signs and symptoms of right-sided HF and severe TR (Stage D) who have undergone previous left-sided valve surgery, reoperation with isolated tricuspid valve surgery may be considered in the absence of severe pulmonary hypertension or severe RV systolic dysfunction(Level of Evidence: B-NR)


References

  1. ↑ Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C (February 2021). "2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines". Circulation. 143 (5): e72–e227. doi:10.1161/CIR.0000000000000923. PMID 33332150 Check |pmid= value (help).
  2. ↑ Rogers JH, Bolling SF (May 2009). "The tricuspid valve: current perspective and evolving management of tricuspid regurgitation". Circulation. 119 (20): 2718–25. doi:10.1161/CIRCULATIONAHA.108.842773. PMID 19470900.
  3. ↑ Chikwe J, Anyanwu AC (2010). "Surgical strategies for functional tricuspid regurgitation". Semin Thorac Cardiovasc Surg. 22 (1): 90–6. doi:10.1053/j.semtcvs.2010.05.002. PMID 20813324.
  4. ↑ Kadri AN, Menon V, Sammour YM, Gajulapalli RD, Meenakshisundaram C, Nusairat L, Mohananey D, Hernandez AV, Navia J, Krishnaswamy A, Griffin B, Rodriguez L, Harb SC, Kapadia S (December 2019). "Outcomes of patients with severe tricuspid regurgitation and congestive heart failure". Heart. 105 (23): 1813–1817. doi:10.1136/heartjnl-2019-315004. PMID 31422359.
  5. ↑ Mangoni AA, DiSalvo TG, Vlahakes GJ, Polanczyk CA, Fifer MA (January 2001). "Outcome following isolated tricuspid valve replacement". Eur J Cardiothorac Surg. 19 (1): 68–73. doi:10.1016/s1010-7940(00)00598-4. PMID 11163563.
  6. ↑ Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W (February 2022). "2021 ESC/EACTS Guidelines for the management of valvular heart disease". Eur Heart J. 43 (7): 561–632. doi:10.1093/eurheartj/ehab395. PMID 34453165 Check |pmid= value (help).
  7. ↑ Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C (February 2021). "2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines". Circulation. 143 (5): e35–e71. doi:10.1161/CIR.0000000000000932. PMID 33332149 Check |pmid= value (help).
  8. ↑ 8.0 8.1 Rodés-Cabau J, Taramasso M, O'Gara PT (2016). "Diagnosis and treatment of tricuspid valve disease: current and future perspectives". Lancet. 388 (10058): 2431–2442. doi:10.1016/S0140-6736(16)00740-6. PMID 27048553 PMID: 27048553 Check |pmid= value (help).
  9. ↑ Taramasso M, Vanermen H, Maisano F, Guidotti A, La Canna G, Alfieri O (2012). "The growing clinical importance of secondary tricuspid regurgitation". J Am Coll Cardiol. 59 (8): 703–10. doi:10.1016/j.jacc.2011.09.069. PMID 22340261.
  10. ↑ "A Case of Traumatic Tricuspid Regurgitation Caused by Multiple Papillary Muscle Rupture".
  11. ↑ Altaani HA, Jaber S (June 2013). "Tricuspid Valve Replacement, Mechnical vs. Biological Valve, Which Is Better?". Int Cardiovasc Res J. 7 (2): 71–4. PMC 3987430. PMID 24757625.
  12. ↑ Lu FL, An Z, Ma Y, Song ZG, Cai CL, Li BL, Zhou GW, Han L, Wang J, Bai YF, Liu XH, Wang JF, Meng X, Zhang HB, Yang J, Dong NG, Hu SS, Pan XB, Cheung A, Qiao F, Xu ZY (October 2021). "Transcatheter tricuspid valve replacement in patients with severe tricuspid regurgitation". Heart. 107 (20): 1664–1670. doi:10.1136/heartjnl-2020-318199. PMID 33419880 Check |pmid= value (help).
  13. ↑ Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F; et al. (2021). "2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines". Circulation. 143 (5): e72–e227. doi:10.1161/CIR.0000000000000923. PMID 33332150 Check |pmid= value (help).

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