Tricuspid regurgitation, right ventricular function, and renal congestion: a cardiorenal triangle

Abstract

There is a growing interest in the evaluation of tricuspid regurgitation due to its increasing prevalence and detrimental impact on clinical outcomes. Historically, it has been coined the "forgotten" defect in the field of valvular heart disease due to the lack of effective treatments to improve prognosis. However, the development of percutaneous treatment techniques has led to a new era in its management, with promising results and diminished complication risk. In spite of these advances, a comprehensive exploration of the pathophysiological mechanisms is essential to establish clear indications and optimal timing for medical and percutaneous intervention. This review will address the most important aspects related to the diagnosis, pathophysiology and treatment of tricuspid regurgitation from a cardiorenal perspective, with a special emphasis on the interaction between right ventricular dysfunction and the development of hepatorenal congestion.

Keywords: abdominal congestion; cardiorenal; diuretic resistance; heart failure; right ventricular function; tricuspid regurgitation; ultrafiltration.

Figure 1

Pathophysiology, congestion diagnosis and treatment of tricuspid regurgitation. As tricuspid regurgitation progresses, it leads to right ventricular dilatation and dysfunction, worsening the prognosis. In addition, increased venous pressure and reduced stroke volume, cause congestion and affect hepatic and renal haemodynamics. Hence, a valuable tool for assessing congestion is the VExUS ultrasound protocol, which measures inferior vena cava diameter and portal, hepatic and intra-renal Doppler patterns. Treatment includes management of congestive state and tricuspid valve intervention, where percutaneous options are emerging. Key questions remain regarding the optimal timing and efficacy of percutaneous treatments. VExUS, Venous Ultrasound Score Excess; RBF, renal blood flow; RV, right ventricle; Na, sodium, H₂O.