/* 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary{{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
/* 2008 and Incorporated 2006 ACC/AHA Guidelines for the Management of Patients with Valvular Heart Disease (DO NOT EDIT) {{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 Managemen...
**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>
**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>
==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>
|-
| 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>
|}
{|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>
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.
Surgery
Indications for Surgery
Recommendations for intervention in tricuspid valve disease
The above table adopted from 2021 ESC Guideline[1]
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.[2][3]
Determine the stage of the tricuspid regurgitation (TR)
The principal surgical repair for secondary TR is tricuspidannuloplasty. The aim of tricuspid annuloplasty is to improve leaflet coaptation by correcting annular dilatation and restoring annular geometry. The two principle surgical methods are:[4][5]
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 sutureannuloplasty and the risk of postoperative conduction disturbances is lower.
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 [6]
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
Should be undertaken when valve repair is not technically feasible or predictably durable.
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 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:
This is an experimental study that has been carried out in animals (ewes), it is yet to be done in humans.[7]
References
↑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. PMID34453165Check |pmid= value (help).
