Tricuspid regurgitation surgery

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Rim Halaby, M.D. [2]

Overview

In most cases, surgery is not indicated since the root problem lies with a dilated or damaged right ventricle. Medical therapy with diuretics is the mainstay of treatment. Unfortunately, this can lead to volume depletion and decreased cardiac output. Indeed, one must often accept a certain degree of symptomatic tricuspid insufficiency in order to prevent a decrease in cardiac output. Treatment with medicines to reduce cardiac afterload may also be of benefit but a similar risk of depressed cardiac output applies.

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.

Determine the stage of the tricuspid regurgitation (TR)

Progressive functional (Stage B)

Asymptomatic severe (Stage C)

Symptomatic severe (Stage D)

Is TR mild or moderate?

What is the underlying cause of TR?

Has the TR been previously operated on?

Yes

No

What is the underlying cause of TR?

Mild

Moderate

Functional

Primary

Functional

Primary

The patient is undergoing left-sided valve surgery

The patient is undergoing left-sided valve surgery

The patient is experiencing progressive right ventricular dysfunction AND/OR systolic dysfunction

The patient has persistent symptoms AND The patient has preserved right ventricular function and the pulmonary hypertension is not severe

The patient is undergoing left-sided valve surgery

The patient has tricuspid annular dilatation OR Prior evidence of right heart failure

The patient has pulmonary hypertension without tricuspid annular dilatation

2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary

Class IIa

"1. Diuretics can be useful for patients with severe TR and signs of right-sided heart failure (stage D). (Level of Evidence: C)"

Class IIb

"1. Medical therapies to reduce elevated pulmonary artery pressures and/or pulmonary vascular resistance might be considered in patients with severe functional TR (stages C and D). (Level of Evidence: C)"

Surgical Intervention

Class I

"1. Tricuspid valve surgery is recommended for patients with severe TR (stages C and D) undergoing left-sided valve surgery. (Level of Evidence: B)"

Class IIa

"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: Tricuspid annular dilation or Prior evidence of right heart failure. (Level of Evidence: B)"

"2. Tricuspid valve surgery can be beneficial for patients with symptoms due to severe primary TR that are unresponsive to medical therapy (stage D). (Level of Evidence: C)"

Class IIb

"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. (Level of Evidence: C)"

"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. (Level of Evidence: C)"

"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. (Level of Evidence: C)"

2008 and Incorporated 2006 ACC/AHA Guidelines for the Management of Patients with Valvular Heart Disease (DO NOT EDIT)

Tricuspid Valve Replacement (DO NOT EDIT)

Class I

"1. Tricuspid valve repair is beneficial for severe TR in patients with mitral valve disease requiring mitral valve surgery. (Level of Evidence: B)"

Class III

"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. (Level of Evidence: C)"

"2. Tricuspid valve replacement or annuloplasty is not indicated in patients with mild primary TR. (Level of Evidence: C)"

Class IIa

"1. Tricuspid valve replacement or annuloplasty is reasonable for severe primary TR when symptomatic. (Level of Evidence: C)"

"2. Tricuspid valve replacement is reasonable for severe TR secondary to diseased/abnormal tricuspid valve leaflets not amenable to annuloplasty or repair. (Level of Evidence: C)"

Class IIb

"1. Tricuspid valve replacement or annuloplasty is reasonable for severe primary TR when symptomatic. (Level of Evidence: C)"

Indications for Intervention Adolescents (DO NOT EDIT)

Class I

"1. Surgery for severe TR is recommended for adolescent and young adult patients with deteriorating exercise capacity (NYHA functional class III or IV). (Level of Evidence: C)"

"2. Surgery for severe TR is recommended for adolescent and young adult patients with progressive cyanosis and arterial saturation less than 80% at rest or with exercise. (Level of Evidence: C)"

"3. 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. (Level of Evidence: C)"

Class IIa

"1. Surgery for severe TR is reasonable in adolescent and young adult patients with NYHA functional class II symptoms if the valve appears to be repairable. (Level of Evidence: C)"

"2. Surgery for severe TR is reasonable in adolescent and young adult patients with atrial fibrillation. (Level of Evidence: C)"

Class IIb

"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%. (Level of Evidence: C)"

"2. Surgery for severe TR may be considered in asymptomatic adolescent and young adult patients with stable heart size and an arterial saturation of less than 85% when the tricuspid valve appears repairable. (Level of Evidence: C)"

"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 interventional catheterization may be considered when the valve does not appear amenable to repair. (Level of Evidence: C)"

"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. (Level of Evidence: C)"

Tricuspid Valve Surgery (DO NOT EDIT)

Class I

"1. Severe TR in the setting of surgery for multivalvular disease should be corrected. (Level of Evidence: C)"

Class IIa

"1. Tricuspid annuloplasty is reasonable for mild TR in patients undergoing MV surgery when there is pulmonary hypertension or tricuspid annular dilatation. (Level of Evidence: C)"

Intraoperative Assessment (DO NOT EDIT)

Class I

"1. Intraoperative transesophageal echocardiography is recommended for valve repair surgery. (Level of Evidence: B)"

"2. Intraoperative transesophageal echocardiography is recommended for valve replacement surgery with a stentless xenograft, homograft, or autograft valve.(Level of Evidence: B)"

Class IIa

"1. Intraoperative transesophageal echocardiography is reasonable for all patients undergoing cardiac valve surgery. (Level of Evidence: C)"

Sources

• 2008 ACC/AHA Guidelines incorporated into the 2006 guidelines for the management of patients with valvular heart disease