Isolated tricuspid regurgitation: outcomes and therapeutic interventions

Abstract

Isolated tricuspid regurgitation (TR) can be caused by primary valvular abnormalities such as flail leaflet or secondary annular dilation as is seen in atrial fibrillation, pulmonary hypertension and left heart disease. There is an increasing recognition of a subgroup of patients with isolated TR in the absence of other associated cardiac abnormalities. Left untreated isolated TR significantly worsens survival. Stand-alone surgery for isolated TR is rarely performed due to an average operative mortality of 8%-10% and a paucity of data demonstrating improved survival. When surgery is performed, valve repair may be preferred over replacement; however, there is a risk of significant recurrent regurgitation after repair. Existing society guidelines do not fully address the management of isolated TR. We propose that patients at low operative risk with symptomatic severe isolated TR and no reversible cause undergo surgery prior to the onset of right ventricular dysfunction and end-organ damage. For patients at increased surgical risk novel percutaneous interventions may offer an alternative treatment but further research is needed. Significant knowledge gaps remain and future research is needed to define operative outcomes and provide comparative data for medical and surgical therapy.

Keywords: transcatheter valve interventions; tricuspid valve disease; valve disease surgery.

Figure 1

(Online video): Echocardiographic evaluation of severe tricuspid regurgitation. Panel (A) demonstrates right ventricular and atrial enlargement with subsequent leaflet malcoaptation. Panel (B) shows a broad-based regurgitant jet across the tricuspid valve by colour-flow Doppler. Panel (C) highlights the classic ‘dagger-shaped’ continuous wave Doppler pattern of the regurgitant jet which results from rapid pressure equalisation in the right atria and ventricle. Panel (D) demonstrates the continuous wave Doppler pattern of systolic reversals observed in the hepatic veins.

Figure 2

Secondary tricuspid regurgitation is typically mediated by right ventricular and annular dilation with resultant flattening of the normal ‘saddle-shaped’ configuration of the tricuspid valve.

Figure 3

The aetiology of tricuspid regurgitation can be divided according to the presence or absence of organic valvular disease. Patients with isolated primary or secondary tricuspid regurgitation (highlighted in the red boxes) represent an emerging patient population about whom little is known. AF, atrial fibrillation; ARVD, arrhythmogenic right ventricular dysplasia; AV, aortic valve; DCM, dilated cardiomyopathy; L TGA,  L-transposition of the great arteries; RV, right ventricle.

Figure 4

Simultaneous measurement of the tricuspid regurgitation jet by continuous wave Doppler and haemodynamic catheterisation demonstrates several key findings. Severe regurgitation results in rapid pressure equalisation between the right ventricle and right atrium giving the continuous wave Doppler signal a ‘dagger-shaped’ appearance. Additionally, the peak regurgitant velocity is low, which excludes significant pulmonary hypertension as a cause of the regurgitation. The haemodynamic tracing is notable for ventricularisation of the right atrial tracing, and marked elevation of the right atrial pressure with a large C-V wave. RA, right atrium; RV, right ventricle; PG, pressure gradient.

Figure 5

The most common tricuspid valve operations include the Kay bicuspidisation (A), DeVega suture annuloplasty (B), prosthetic annuloplasty band (C) and tricuspid valve replacement (D). AVN, atrioventricular node; CS, coronary sinus; A, anterior leaflet; P, posterior leaflet; S, septal leaflet.

Figure 6

Algorithm for the management of severe isolated tricuspid regurgitation. RA, right atrium; RV, right ventricle; TV, tricuspid valve.

Figure 7

Multiple percutaneous devices are in development for the treatment of tricuspid regurgitation. Panel (A) is the FORMA device, a tricuspid spacer which occupies the regurgitant orifice and provides a surface against which coaptation can occur. Panel (B) demonstrates the TriAlign, which percutaneously reproduces a surgical Kay bicuspidisation. Panel (C) shows the MitraClip being used in the tricuspid position. Panel (D) demonstrates a stented caval valve implanted in the inferior vena cava.