Management and prognosis of tricuspid regurgitation
- Catherine M Otto, MD
Catherine M Otto, MD
- Editor-in-Chief — Cardiovascular Medicine
- Section Editor — Cardiac Evaluation; Valvular Disease
- Professor of Medicine
- University of Washington
Tricuspid regurgitation (TR) is a relatively common abnormality. Since this lesion is frequently asymptomatic and may not be detected on physical examination, it is often diagnosed solely by echocardiography. This topic will review the prognosis and management of TR.
Etiology, clinical features, and evaluation of TR are discussed separately. (See "Etiology, clinical features, and evaluation of tricuspid regurgitation".)
While the clinical setting (particularly concomitant cardiovascular disease) influences survival in patients with tricuspid regurgitation (TR), severe TR is an independent predictor of mortality, as illustrated by the following studies:
●In a study of 5223 patients (mean age 67 years) at three Veterans Affairs medical centers, one-year survival rates were 92, 90, 79, and 64 percent in patient groups with no, mild, moderate, or severe TR, respectively . The causes of TR were not specified. Moderate or greater TR was associated with increased mortality regardless of pulmonary artery systolic pressure or left ventricular ejection fraction (LVEF). Severe TR, age, LVEF, inferior vena cava dilation, and moderate or greater right ventricular (RV) enlargement were associated with impaired survival.
●In a study of 1421 patients with an LVEF ≤35 percent, 34 percent had moderate to severe TR . Severe TR was an independent predictor of mortality along with severe mitral regurgitation, cancer, coronary artery disease, heart rate, and LVEF.
- Nath J, Foster E, Heidenreich PA. Impact of tricuspid regurgitation on long-term survival. J Am Coll Cardiol 2004; 43:405.
- Koelling TM, Aaronson KD, Cody RJ, et al. Prognostic significance of mitral regurgitation and tricuspid regurgitation in patients with left ventricular systolic dysfunction. Am Heart J 2002; 144:524.
- Lee JW, Song JM, Park JP, et al. Long-term prognosis of isolated significant tricuspid regurgitation. Circ J 2010; 74:375.
- Arsalan M, Walther T, Smith RL 2nd, Grayburn PA. Tricuspid regurgitation diagnosis and treatment. Eur Heart J 2017; 38:634.
- Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC guideline 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. J Am Coll Cardiol 2014; 63:e57.
- Hamilton MA, Stevenson LW, Child JS, et al. Sustained reduction in valvular regurgitation and atrial volumes with tailored vasodilator therapy in advanced congestive heart failure secondary to dilated (ischemic or idiopathic) cardiomyopathy. Am J Cardiol 1991; 67:259.
- Song JM, Kang DH, Song JK, et al. Outcome of significant functional tricuspid regurgitation after percutaneous mitral valvuloplasty. Am Heart J 2003; 145:371.
- Hannoush H, Fawzy ME, Stefadouros M, et al. Regression of significant tricuspid regurgitation after mitral balloon valvotomy for severe mitral stenosis. Am Heart J 2004; 148:865.
- Shafie MZ, Hayat N, Majid OA. Fate of tricuspid regurgitation after closed valvotomy for mitral stenosis. Chest 1985; 88:870.
- Sadeghi HM, Kimura BJ, Raisinghani A, et al. Does lowering pulmonary arterial pressure eliminate severe functional tricuspid regurgitation? Insights from pulmonary thromboendarterectomy. J Am Coll Cardiol 2004; 44:126.
- Bonow RO, Cheitlin MD, Crawford MH, Douglas PS. Task Force 3: valvular heart disease. J Am Coll Cardiol 2005; 45:1334.
- Bonow RO, Nishimura RA, Thompson PD, Udelson JE. Eligibility and Disqualification Recommendations for Competitive Athletes With Cardiovascular Abnormalities: Task Force 5: Valvular Heart Disease: A Scientific Statement From the American Heart Association and American College of Cardiology. J Am Coll Cardiol 2015; 66:2385.
- Joint Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology (ESC), European Association for Cardio-Thoracic Surgery (EACTS), Vahanian A, et al. Guidelines on the management of valvular heart disease (version 2012). Eur Heart J 2012; 33:2451.
- Dreyfus GD, Corbi PJ, Chan KM, Bahrami T. Secondary tricuspid regurgitation or dilatation: which should be the criteria for surgical repair? Ann Thorac Surg 2005; 79:127.
- Chan V, Burwash IG, Lam BK, et al. Clinical and echocardiographic impact of functional tricuspid regurgitation repair at the time of mitral valve replacement. Ann Thorac Surg 2009; 88:1209.
- Matsunaga A, Duran CM. Progression of tricuspid regurgitation after repaired functional ischemic mitral regurgitation. Circulation 2005; 112:I453.
- Song H, Kim MJ, Chung CH, et al. Factors associated with development of late significant tricuspid regurgitation after successful left-sided valve surgery. Heart 2009; 95:931.
- Kara I, Koksal C, Erkin A, et al. Outcomes of Mild to Moderate Functional Tricuspid Regurgitation in Patients Undergoing Mitral Valve Operations: A Meta-Analysis of 2,488 Patients. Ann Thorac Surg 2015; 100:2398.
- Kim YJ, Kwon DA, Kim HK, et al. Determinants of surgical outcome in patients with isolated tricuspid regurgitation. Circulation 2009; 120:1672.
- Scully HE, Armstrong CS. Tricuspid valve replacement. Fifteen years of experience with mechanical prostheses and bioprostheses. J Thorac Cardiovasc Surg 1995; 109:1035.
- Carrier M, Hébert Y, Pellerin M, et al. Tricuspid valve replacement: an analysis of 25 years of experience at a single center. Ann Thorac Surg 2003; 75:47.
- Marquis-Gravel G, Bouchard D, Perrault LP, et al. Retrospective cohort analysis of 926 tricuspid valve surgeries: clinical and hemodynamic outcomes with propensity score analysis. Am Heart J 2012; 163:851.
- Góngora E, Dearani JA, Orszulak TA, et al. Tricuspid regurgitation in patients undergoing pericardiectomy for constrictive pericarditis. Ann Thorac Surg 2008; 85:163.
- Guenther T, Noebauer C, Mazzitelli D, et al. Tricuspid valve surgery: a thirty-year assessment of early and late outcome. Eur J Cardiothorac Surg 2008; 34:402.
- Moraca RJ, Moon MR, Lawton JS, et al. Outcomes of tricuspid valve repair and replacement: a propensity analysis. Ann Thorac Surg 2009; 87:83.
- Starck CT, Kempfert J, Falk V. Tricuspid valve interventions: surgical techniques and outcomes. EuroIntervention 2015; 11 Suppl W:W128.
- Ghanta RK, Chen R, Narayanasamy N, et al. Suture bicuspidization of the tricuspid valve versus ring annuloplasty for repair of functional tricuspid regurgitation: midterm results of 237 consecutive patients. J Thorac Cardiovasc Surg 2007; 133:117.
- McCarthy PM, Bhudia SK, Rajeswaran J, et al. Tricuspid valve repair: durability and risk factors for failure. J Thorac Cardiovasc Surg 2004; 127:674.
- Navia JL, Nowicki ER, Blackstone EH, et al. Surgical management of secondary tricuspid valve regurgitation: annulus, commissure, or leaflet procedure? J Thorac Cardiovasc Surg 2010; 139:1473.
- Singh SK, Tang GH, Maganti MD, et al. Midterm outcomes of tricuspid valve repair versus replacement for organic tricuspid disease. Ann Thorac Surg 2006; 82:1735.
- Ren WJ, Zhang BG, Liu JS, et al. Outcomes of tricuspid annuloplasty with and without prosthetic rings: a retrospective follow-up study. J Cardiothorac Surg 2015; 10:81.
- Fukuda S, Song JM, Gillinov AM, et al. Tricuspid valve tethering predicts residual tricuspid regurgitation after tricuspid annuloplasty. Circulation 2005; 111:975.
- Dreyfus GD, Raja SG, John Chan KM. Tricuspid leaflet augmentation to address severe tethering in functional tricuspid regurgitation. Eur J Cardiothorac Surg 2008; 34:908.
- Meng H, Pan SW, Hu SS, et al. Surgical Treatment of Secondary Tricuspid Regurgitation: Insight Derived From Annulus Sizes and Tethering Distances. Ann Thorac Surg 2015; 100:1238.
- Ratnatunga CP, Edwards MB, Dore CJ, Taylor KM. Tricuspid valve replacement: UK Heart Valve Registry mid-term results comparing mechanical and biological prostheses. Ann Thorac Surg 1998; 66:1940.
- Van Nooten GJ, Caes F, Taeymans Y, et al. Tricuspid valve replacement: postoperative and long-term results. J Thorac Cardiovasc Surg 1995; 110:672.
- Do QB, Pellerin M, Carrier M, et al. Clinical outcome after isolated tricuspid valve replacement: 20-year experience. Can J Cardiol 2000; 16:489.
- Sung K, Park PW, Park KH, et al. Is tricuspid valve replacement a catastrophic operation? Eur J Cardiothorac Surg 2009; 36:825.
- Filsoufi F, Anyanwu AC, Salzberg SP, et al. Long-term outcomes of tricuspid valve replacement in the current era. Ann Thorac Surg 2005; 80:845.
- Rizzoli G, Vendramin I, Nesseris G, et al. Biological or mechanical prostheses in tricuspid position? A meta-analysis of intra-institutional results. Ann Thorac Surg 2004; 77:1607.
- Shrestha BM, Fukushima S, Vrtik M, et al. Partial replacement of tricuspid valve using cryopreserved homograft. Ann Thorac Surg 2010; 89:1187.
- Latib A, Agricola E, Pozzoli A, et al. First-in-Man Implantation of a Tricuspid Annular Remodeling Device for Functional Tricuspid Regurgitation. JACC Cardiovasc Interv 2015; 8:e211.
- Bouleti C, Juliard JM, Himbert D, et al. Tricuspid valve and percutaneous approach: No longer the forgotten valve! Arch Cardiovasc Dis 2016; 109:55.
- O'Brien SM, Shahian DM, Filardo G, et al. The Society of Thoracic Surgeons 2008 cardiac surgery risk models: part 2--isolated valve surgery. Ann Thorac Surg 2009; 88:S23.
- Ambler G, Omar RZ, Royston P, et al. Generic, simple risk stratification model for heart valve surgery. Circulation 2005; 112:224.
- Roques F, Nashef SA, Michel P, et al. Risk factors and outcome in European cardiac surgery: analysis of the EuroSCORE multinational database of 19030 patients. Eur J Cardiothorac Surg 1999; 15:816.
- Nashef SA, Roques F, Michel P, et al. European system for cardiac operative risk evaluation (EuroSCORE). Eur J Cardiothorac Surg 1999; 16:9.
- Al-Mohaissen MA, Chan KL. Prevalence and mechanism of tricuspid regurgitation following implantation of endocardial leads for pacemaker or cardioverter-defibrillator. J Am Soc Echocardiogr 2012; 25:245.
- Nazmul MN, Cha YM, Lin G, et al. Percutaneous pacemaker or implantable cardioverter-defibrillator lead removal in an attempt to improve symptomatic tricuspid regurgitation. Europace 2013; 15:409.
- Mazine A, Bouchard D, Moss E, et al. Transvalvular pacemaker leads increase the recurrence of regurgitation after tricuspid valve repair. Ann Thorac Surg 2013; 96:816.
- Molina JE, Roberts CL, Benditt DG. Long-term follow-up of permanent transvenous pacing systems preserved during tricuspid valve replacement. Ann Thorac Surg 2010; 89:318.
- APPROACH TO MANAGEMENT
- MEDICAL MANAGEMENT
- Treatment of heart failure
- Treatment of causes of pulmonary hypertension
- Physical activity and exercise
- TRICUSPID VALVE SURGERY
- - At the time of left-sided valve surgery
- - For isolated tricuspid valve surgery
- - At the time of pericardiectomy
- Repair versus replacement
- - Valve repair
- - Valve replacement
- Transcatheter tricuspid valve repair or replacement
- Timing and risk stratification
- Management of leads
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS