Tricuspid regurgitation: when is it time for surgery?

ABSTRACT

Introduction: The interest in tricuspid regurgitation (TR) surgical treatment has grown in the last years, mostly motivated by the trend for early intervention and the development of minimally invasive surgical techniques. Despite this, there is still a lack of evidence regarding when to intervene in functional tricuspid regurgitation outside the context of left-sided valve surgery and when is the best time to approach primary tricuspid regurgitation.

Areas covered: Herein, we present the state-of-the-art in tricuspid regurgitation surgical intervention, covering indications, optimum time, surgical options, and outcomes, as well as the role of transcatheter tricuspid valve intervention in the current era.

Expert opinion: Current evidence support that the indications and timing of tricuspid valve invasive management should be centered on a range of factors, including patients’ characteristics, disease stage, and anatomical considerations. Early intervention, before severe right ventricle dysfunction and pulmonary hypertension, seems to results in better postoperative outcomes. Transcatheter techniques are arising as potential alternatives for inoperable and high-risk patients.

KEYWORDS:

• Tricuspid intervention
• tricuspid regurgitation
• tricuspid valve
• annuloplasty
• valve repair
• valve replacement

Article highlights

• Right-sided cardiac diseases have traditionally been considered less relevant than mitral and aortic valve pathologies. Particularly in the last years, however, the concept of early tricuspid regurgitation intervention and the trends for transcatheter structural heart interventions led to a growing interest in tricuspid valve diseases.

• In the setting of functional tricuspid regurgitation concomitant with a left-sided valvar disease, intervention based on annulus dilatation rather than on tricuspid regurgitation severity has been associated with reduced tricuspid regurgitation recurrence or progression and improved long-term survival.

• In isolated tricuspid regurgitation, however, there is still a lack of surgical data showing a substantial survival benefit when the surgical approach is compared to medical management.

• The decision-making process for tricuspid regurgitation intervention should be made by a Heart Team and centered on individual factors such as patient desire, clinical symptoms, response to medical management, quality of life and life expectancy, tricuspid valve morphology, devices availability, and procedural risks.

• For patients at increased surgical risk, novel percutaneous interventions may offer alternative treatment, but further research is needed.

Acknowledgments

The authors thank Luca Vicentini for his support with the images.

Declaration of interest

AP Tagliari has received a Research Grant from Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - Brasil (Capes) - Finance Code 001. M Taramasso is a consultant for Abbott Vascular, Boston Scientific and 4tech; and has received Consultant fees from Edwards Lifesciences, CoreMedic, SwissVortex and Mitraltech. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose. 

Additional information

Funding

This paper was not funded.