Basic pathophysiology and options of treatment for surgical management of functional tricuspid regurgitation: a systematic review

Abstract

Background: Functional tricuspid regurgitation (TR) appears frequently in the presence of left-sided heart valve diseases, combined with symptoms of heart failure, worsens if left untreated, and is associated with poor patient survival. Correct indications for surgery and the choice of suitable technique, which should be based on pathophysiology of disease are of utmost importance to ensure longevity and durability of repair; particularly given the risky nature of reoperations due to residual/recurrent TR.

Methods: A systematic review was performed using Embase, Ovid Medline, Cochrane, Web of Science, and Google to deepen knowledge of major and controversial aspects of the subject.

Results: A total of 1,579 studies were reviewed, and 32 of these were enclosed in the final review: 13 studies were primarily focused on pathophysiology and preoperative assessment of functional TR; 19 studies on surgical treatment of functional TR. A total of 15,509 patients were included.

Conclusions: Indications for treatment of TR are based on the severity of regurgitation (grading), as well as on the presence of signs and symtoms of right-sided heart failure and on the extent of tricuspid annular dilation, leaflet tethering, and pulmonary hypertension (staging of disease). Despite improved knowledge of the underlying pathophysiology of TR, issues regarding indications for treatment and options of repair remain present. There is no consensus within the scientific community, for the preferred method to quantify the severity of TR; the recently introduced 5-grade TR classification based on objective quantitative parameters has not yet become common practice. The assessment of TR during stress exercise is rarely performed, though it takes into account the changes in severity of regurgitation that occur under different physiological conditions. Magnetic resonance imaging, which is the gold standard for the right heart evaluation is occasionally carried out before surgery. The threshold beyond which the tricuspid annular dilation should be repaired is unclear and recent studies put forward the idea that it may be lower than current recommendations. Tricuspid valve annuloplasty is the most adopted surgical option today. However, the ideal annuloplasty device remains elusive. In addition, as severe leaflet tethering cannot be addressed by annuloplasty alone, the addition of new techniques further increasing leaflet coaptation might optimize long-term valve continence. Further investigations are needed to address all these issues, alongside the potential of percutaneous options.

Keywords: Atrial fibrillation (AF); pulmonary hypertension; right heart failure; tricuspid regurgitation (functional); tricuspid valve surgery.

Figure 1

Basic pathophysiology of fTR (4-9). Two patient populations characterize fTR, which is not properly a tricuspid valve disease based on a different involvement of the right ventricle and RA. In the advanced stages of disease, both populations develop tricuspid annular dilation and require a referral to comprehensive heart valve center. fTR, functional tricuspid regurgitation; LHD, left-sided heart disease; PH, pulmonary hypertension; AF, atrial fibrillation; RA, right atrium.

Figure 2

PRISMA flowchart of the study. **, review, case report and abstract presentation. COPD, chronic obstructive pulmonary disease; TR, tricuspid regurgitation; LVAD, left ventricular assist device.

Figure 3

Tricuspid valve components and surgical anatomy considerations.

Figure 4

Anatomic structures located in proximity of the tricuspid valve and involved in its surgical handling. RA, right atrium; SVC, superior vena cava; IVC, inferior vena cava; AV, atrioventricular.

Figure 5

Clinical algorithm for the management of functional TR based on TTE (according to The 2020 American Heart Association/American College of Cardiology guideline for the management of patients with valvular heart disease) (51). TR, tricuspid regurgitation; TTE, transthoracic echocardiography; IVC, inferior vena cava; RA, right atrium; RV, right ventricle/right ventricular; PAP, pulmonary artery pressure; COR, class of recommendation; LOE, level of evidence; PVR, pulmonary vascular resistances; LD, limited data; NR, nonrandomized; TV, tricuspid valve; HF, heart failure; GDMT, guideline-directed medical therapy; PH, pulmonary hypertension; LVEF, left ventricular ejection fraction.