Diagnostic Management and Surgical Treatment of Isolated Tricuspid Regurgitation (original) (raw)
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Functional Tricuspid Regurgitation in Patients With Pulmonary Hypertension
Chest, 2009
A39yr-old man presented with chest pain, cough, fever, chills, and weight loss. A transthoracic echocardiogram revealed vegetations on the mitral valve (MV) and the aortic valve (AV) with severe mitral regurgitation (MR) and severe aortic regurgitation (AR). No vegetations were seen on the tricuspid valve (TV), but severe tricuspid regurgitation (TR) was noted. The estimated pulmonary artery systolic pressure (PASP) was 71 mm Hg. The left ventricular ejection fraction was normal. The size of the right atrium (RA) and right ventricle (RV) was not mentioned in the report. With a diagnosis of infective endocarditis, the patient was started on antibiotics, furosemide, and hydralazine. After 5 days, a transesophageal echocardiogram (TEE) revealed a mildly dilated left atrium, normal size left ventricle (LV), normal left ventricular ejection fraction, vegetations on the MV and AV, severe MR, severe AR, moderate TR, and a normal PASP. The size of the RA and RV was not mentioned in the report. The patient was now in renal failure requiring dialysis and had some degree of coagulopathy. He was scheduled the following day for MV replacement and AV replacement. The short duration of the disease process, the decrease in PASP, and less TR in response to medical management led to the preoperative assessment that repair of the left-sided lesions would result in resolution of the TR. After induction of general anesthesia, a pulmonary artery catheter was inserted, and a TEE was performed. The right atrial pressure was 30 mm Hg, and the pulmonary artery pressure was 49/33 mm Hg. The TEE confirmed the presence of AV and MV vegetations with severe MR and AR. At this time, the TEE demonstrated a structurally normal TV, a dilated RA, dilated RV,
Diagnosis and Management of Isolated Tricuspid Regurgitation: An Enigma
2019
Secondary or functional Mitral Regurgitation (MR) is well documented. Long-standing MR, Pulmonary Hypertension (PH) or myocardial disease usually leads to Secondary Tricuspid Regurgitation (STR). The following case of chronic Left Ventricular (LV) ischemia and the resultant myocardial scarring causing isolated Tricuspid Regurgitation (TR) without left heart dysfunction has not yet been reported.
General Thoracic and Cardiovascular Surgery, 2016
The assessment and management of tricuspid valve disease have evolved substantially during the past several years. Whereas tricuspid stenosis is uncommon, tricuspid regurgitation is frequently encountered and it is most often secondary due to annular dilatation and leaflet tethering from right ventricular remodelling. The indications for tricuspid valve surgery to treat tricuspid regurgitation are several and mainly related to the underlying disease, to the severity of insufficiency and to the right ventricular function. Surgical tricuspid repair has been avoided for years, because of the misleading concept that tricuspid regurgitation should disappear once the primary left-sided problem has been eliminated. Instead, during the last decade, many investigators have reported evidence in favor of a more aggressive surgical approach to functional tricuspid regurgitation, recognising the risk of progressive tricuspid insufficiency in patients with moderate or lesser degrees of tricuspid regurgitation and tricuspid annular dilatation. This concept, along with the long-term outcomes of principal surgical repair techniques are reported and discussed. Last, novel transcatheter therapies have begun to emerge for the treatment of severe tricuspid regurgitation in high-risk patients. Hence, very preliminary pre-clinical and clinical experiences are illustrated. The scope of this review is to explore the anatomic basis, the pathophysiology, the outcomes and the new insights in the management of functional tricuspid regurgitation.
The Growing Clinical Importance of Secondary Tricuspid Regurgitation
Journal of the American College of Cardiology, 2012
Functional or secondary tricuspid regurgitation (STR) is the most frequent etiology of tricuspid valve pathology in Western countries. Surgical tricuspid repair has been avoided for years, because of the misconception that tricuspid regurgitation should disappear once the primary left-sided problem is treated; this results in a large number of untreated patients with STR. Over the past few years, many investigators have reported evidence in favor of a more aggressive surgical approach to STR. Consequently, interest has been growing in the physiopathology and treatment of STR. The purpose of this review is to explore the anatomical basis, pathophysiology, therapeutic approach, and future perspectives with regard to the management of STR. (J Am Coll Cardiol 2012;59: 703-10)
Functional Tricuspid Regurgitation: Behind the Scenes of a Long-Time Neglected Disease
2022
Severe tricuspid valve regurgitation has been for a long time a neglected valve disease, which has only recently attracted an increasing interest due to the notable negative impact on the prognosis of patients with cardiovascular disease. It is estimated that around 90% of tricuspid regurgitation is diagnosed as "functional" and mostly secondary to a primary left-sided heart disease and, therefore, has been usually interpreted as a benign condition that did not require a surgical management. Nevertheless, the persistence of severe tricuspid regurgitation after left-sided surgical correction of a valve disease, particularly mitral valve surgery, has been associated to adverse outcomes, worsening of the quality of life, and a significant increase in mortality rate. Similar results have been found when the impact of isolated severe tricuspid regurgitation has been studied. Current knowledge is shifting the "functional" categorization toward a more complex and detailed pathophysiological classification, identifying various phenotypes with completely different etiology, natural history and, potentially, an invasive management. The aim of this review is to offer a comprehensive guide for clinicians and surgeons with a systematic description of "functional" tricuspid regurgitation subtypes, an analysis centered on the effectiveness of existing surgical techniques and a focus on the emergent percutaneous procedures. This latter may be an attractive alternative to a standard surgical approach in patients with high-operative risk or isolated tricuspid regurgitation.
Management of Tricuspid Valve Regurgitation
Heart, 2007
Tricuspid regurgitation (TR) is a very frequent manifestation of valvular heart disease. It may be due to the primary involvement of the valve or secondary to pulmonary hypertension or to the left-sided heart valve disease (most commonly rheumatic and involving the mitral valve). The pathophysiology of secondary TR is complex and is intrinsically connected to the anatomy and function of the right ventricle. A systematic multimodality approach to diagnosis and assessment (based not only on the severity of the TR but also on the assessment of annular size, RV function and degree of pulmonary hypertension) is, therefore, essential. Once considered non-important, treatment of secondary TR is currently viewed as an essential concomitant procedure at the time of mitral (and, less frequently, aortic valve) surgery. Although the indications for surgical management of severe TR are now generally accepted (Class I), controversy persists concerning the role of intervention for moderate TR. However, there is a trend for intervention in this setting, especially at the time of surgery for leftsided heart valve disease and/or in patients with significant tricuspid annular dilatation (Class IIa). Currently, surgery remains the best approach for the interventional treatment of TR. Percutaneous tricuspid valve intervention (both repair and replacement) is still in its infancy but may become a reliable option in future, especially for high-risk patients with isolated primary TR or with secondary TR related to advanced left-sided heart valve disease.
Short- and Long-term Outcomes of Surgery for Severe Tricuspid Regurgitation
Revista Española de Cardiología (English Edition), 2013
Introduction and objectives: There is little data available for Spain on the outcomes of surgical treatment for severe tricuspid regurgitation. The aim of this study was to analyze clinical and echocardiographic outcomes in a series of patients who received surgical treatment for severe tricuspid regurgitation and to compare outcomes according to the operative approach to valve repair or replacement. Methods: Retrospective study in 119 consecutive patients with severe tricuspid regurgitation undergoing valve surgery between April 1996 and February 2010. Results: A total of 61 ringless and 23 ring annuloplasties were performed and 11 bioprostheses and 24 mechanical prostheses were implanted. Perioperative mortality was 18.5% and was associated with age and cardiopulmonary bypass time. During clinical follow-up (median, 41 [interquartile range, 24-89] months), 2 reoperations were required in the ring annuloplasty and mechanical prosthesis groups; prosthetic thrombosis was diagnosed in 4 patients in the latter group. Total mortality after follow-up was 29.9% and was associated with age>70 years and extracorporeal circulation time. The emergence of new severe tricuspid regurgitation was associated with age and ringless annuloplasty (P=.04). Conclusions: Ringless repair was significantly associated with recurrence of severe tricuspid regurgitation. The use of mechanical prostheses was associated with a high rate of thrombosis. No significant differences in perioperative or total mortality were found between the different methods used for repair or valve replacement.
Circulation. Cardiovascular interventions, 2018
Transcatheter caval valve implantation is under evaluation as a treatment option for inoperable patients with severe tricuspid regurgitation (TR). The procedure involves the catheter-based implantation of bioprosthetic valves in the inferior vena cava and superior vena cava to treat symptoms associated with TR. This study is the first to evaluate the feasibility, safety, and efficacy of this interventional concept. Twenty-five patients (mean age, 73.9±7.6 years; women, 52.0%) with severe symptomatic TR despite optimal medical treatment deemed unsuitable for surgery were treated with caval valve implantation under a compassionate clinical use program. Technical feasibility defined as procedural success, hemodynamic effect defined as venous pressure reduction, and safety defined as periprocedural adverse events were evaluated, with clinical follow-up at discharge and up to 12 months. The functional impact was evaluated by assessment of New York Heart Association class at the time of h...