Tricuspid regurgitation surgery: Difference between revisions

	Tricuspid Regurgitation Microchapters
Home
Patient Information
Overview
Historical Perspective
Classification
Pathophysiology
Causes
Differentiating Tricuspid Regurgitation from other Diseases
Epidemiology and Demographics
Risk Factors
Screening
Natural History, Complications and Prognosis
Diagnosis
Diagnostic Study of Choice
Stages
History and Symptoms
Physical Examination
Laboratory Findings
Echocardiography
Chest X Ray
Electrocardiogram
Cardiac Stress Test
Cardiac MRI
Cardiac Catheterization
Other Imaging Findings
Other Diagnostic Studies
Treatment
Medical therapy
Surgery
Primary Prevention
Secondary Prevention
Case Studies
Case #1
Tricuspid regurgitation surgery On the Web
Most recent articles
Most cited articles
Review articles
CME Programs
Powerpoint slides
Images
American Roentgen Ray Society Images of Tricuspid regurgitation surgery All Images X-rays Echo & Ultrasound CT Images MRI
Ongoing Trials at Clinical Trials.gov
US National Guidelines Clearinghouse
NICE Guidance
FDA onTricuspid regurgitation surgery
CDC on Tricuspid regurgitation surgery
Tricuspid regurgitation surgery in the news
Blogs on Tricuspid regurgitation surgery
Directions to Hospitals Treating Tricuspid regurgitation
Risk calculators and risk factors for Tricuspid regurgitation surgery

VisualWikitext

Latest revision as of 15:11, 8 December 2022

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

Primary or secondary severe TR may not improve after treatment of the left-sided valve lesion and reduction of RV afterload. ^[1]
Re-operation for severe, isolated TR after left-sided valve surgery is associated with a perioperative mortality rate of 10% to 25%.
Tricuspid valve repair will not increase the risks of surgery.^[2]
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.^[3]
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.
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.
Studies showed the benefits of tricuspid repair at the time of mitral valve surgery for progressive TR (Stage B) with tricuspid annulus dilation.

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.
Quality and duration of long-term survival are related to residual RV function.^[4]
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.
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
TR can develop in attribution with AF and annular dilation (a form of secondary TR).^[5]
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.
These patients with AF-related TR have rapid progression of TR severity and right-sided chamber dilation.
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.

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.

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.
- Bioprosthetic valves are currently favored, however, no significant hemodynamic difference between mechanical and biological valves was observed.^[11]
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

↑ 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).
↑ 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.
↑ 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.
↑ 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.
↑ 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.
↑ 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).
↑ 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).
↑ ^8.0 ^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).
↑ 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.
↑ "A Case of Traumatic Tricuspid Regurgitation Caused by Multiple Papillary Muscle Rupture".
↑ 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.
↑ 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).
↑ 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).

Template:WH Template:WS

[pmid33332150-1] 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).

[pmid19470900-2] 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.

[pmid20813324-3] 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.

[pmid31422359-4] 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.

[pmid11163563-5] 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.

[pmid34453165-6] 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).

[pmid33332149-7] 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).

[pmidPMID:_27048553-8] 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).

[pmid22340261-9] 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".

[pmid24757625-11] 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.

[pmid33419880-12] 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).

[pmid333321502-13] 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).

[1]

[2]

[3]

[4]

[5]

[6]

[7]

[8]

[9]

[10]

[11]

[12]

[13]

@@ Line 1: / Line 1: @@
 __NOTOC__
 {{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==
-Severe primary/secondary [[tricuspid regurgitation]] does not predictably improve after left-sided [[valve]] surgery, even with correction of any associated [[pulmonary hypertension]], and should be addressed at the time of the index left-sided [[valve]] surgery.
+[[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===
+* 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>
+*Re-operation for severe, isolated [[TR]] after left-sided [[valve]] surgery is associated with a [[perioperative]] [[mortality rate]] of 10% to 25%.
+* [[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>
+* [[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>
+* 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.
+*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.
+* Studies showed the benefits of [[tricuspid repair]] at the time of [[mitral]] valve [[surgery]] for [[progressive TR]] (Stage B) with [[tricuspid]] annulus dilation.
+*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]].
+* 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]].
+* 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]]
+*[[ 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]].
+* These [[patients]] with [[AF]]-related [[TR]] have rapid progression of [[TR]] severity and right-sided chamber [[dilation]].
+* 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]].
 {| style="cellpadding=0; cellspacing= 0; width: 800px;"
 |-
@@ Line 51: / Line 79: @@
+{{familytree/start}}
+{{familytree | | | | | | | | | B01 | | | | | |B01=[[Tricuspid regurgitation]]}}
+{{familytree | | |,|-|-|-|-|-|-|^|-|-|-|-|-|-|.| }}
+{{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>
+{|
+! 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>
+|-
+|}
-* 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><ref name="pmid27048553">{{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=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>
-{{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}}<br><br>
 ===Surgical Methods===
@@ Line 133: / Line 140: @@
 |}
 * '''Tricuspid valve replacement'''
-**Should be undertaken when valve repair is not technically feasible or predictably durable.
+*The initial approach in [[tricuspid]] surgery is repair; however, replacement is done whenever the valve is badly diseased.
-**Valve repair should be considered as the 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 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>
-**[[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 [[Valve|valves]].
 * '''Transcatheter therapies'''
-**The safety and feasibility of transcatheter therapies for treating severe [[tricuspid regurgitation]] are still being investigated.
+**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]]
@@ Line 143: / Line 149: @@
 **#Coaptation device
-* '''Transcatheter tricuspid valve replacement'''
+* '''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>
-**This is an experimental study that has been carried out in animals (ewes), it is yet to be done in humans.<ref name="pmid16022968">Boudjemline Y, Agnoletti G, Bonnet D, Behr L, Borenstein N, Sidi D et al. (2005) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=16022968 Steps toward the percutaneous replacement of atrioventricular valves an experimental study.] ''J Am Coll Cardiol'' 46 (2):360-5. [http://dx.doi.org/10.1016/j.jacc.2005.01.063 DOI:10.1016/j.jacc.2005.01.063] PMID: [https://pubmed.gov/PMID 16022968 PMID 16022968]</ref>
-==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>==
+== 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.''' 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>
+| 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]]
 |-
-| 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:
+| colspan="1" style="text-align:center; background:LemonChiffon" |[[ESC guidelines classification scheme#Classification of Recommendations|Class IIa]]
-* 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>
+| 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]])''
+.   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]])''
+.   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"
-{|class="wikitable"
-|-
-| 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 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>
-|-
-| 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>
-|-
-| 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]]
-|-
-| 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>
-|}
-{|class="wikitable"
-|-
-| colspan="1" style="text-align:center; background:LightCoral"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]]
-|-
-| 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>
-|}
-{|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.''' 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>
-|-
-| 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>
-|}
-{|class="wikitable"
-|-
-| 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>
-|}
-===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"
-|-
-| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
 |-
-| 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>
+| colspan="1" style="text-align:center; background:LemonChiffon" |[[ESC guidelines classification scheme#Classification of Recommendations|Class IIb]]
 |-
-| 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>
+| 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)]]''
+.   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 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>===
-{|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.''' 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>
-|}
-{|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.''' 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>
-|}
-===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>
-|-
-| 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>
-|}
-{|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>
-|}
 ==References==

Tricuspid regurgitation surgery: Difference between revisions

Latest revision as of 15:11, 8 December 2022

Overview

Surgery

Indications for Surgery

Surgical Methods

Annuloplasty

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

References

Navigation menu

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]