Tricuspid Regurgitation

Tricuspid regurgitation (TR) is systolic backflow from the right ventricle into the right atrium.

Functional (secondary) TR accounts for about 90%: right ventricular dilatation from left heart disease, pulmonary hypertension, annular dilatation (atrial fibrillation), cardiomyopathy.

Primary TR: endocarditis (injection drug use), Ebstein anomaly, rheumatic, carcinoid, myxomatous prolapse, trauma, pacemaker or defibrillator lead interference, radiation, drugs (anorexigens, ergot derivatives).

Prevalence of moderate or greater TR is about 0.5 to 1% overall and 4% in those over 75.

Severity grades: mild, moderate, severe, massive, torrential (vena contracta 7 mm or more, effective regurgitant orifice 40 mm2 or more, hepatic vein systolic reversal).

Consequences: right heart failure, atrial fibrillation, renal and hepatic congestion (cardiac cirrhosis), cachexia.

• Fatigue, abdominal swelling, oedema, right upper quadrant pain, dyspnoea, ascites, anorexia.
• Prominent v waves and Kussmaul sign, pulsatile hepatomegaly, holosystolic murmur at lower left sternal border increasing with inspiration (Carvallo sign), right ventricular heave.
• Atrial fibrillation.

• Echocardiography: annular diameter (over 40 mm or 21 mm/m2 dilated), leaflet morphology, right ventricular size and function (TAPSE, S'), systolic pulmonary pressure, lead interaction, inferior vena cava size.
• Cardiac MRI for right ventricular volumes; CT for annulus and anatomy for transcatheter therapy.
• Right heart catheterisation for pulmonary hypertension and resistance.
• Liver tests, renal function, NT proBNP.

Medical

• Treat the cause (pulmonary hypertension, left heart disease, rhythm control).
• Diuretics: furosemide 40 to 160 mg with spironolactone 50 to 100 mg and sometimes metolazone 2.5 to 5 mg; SGLT2 inhibitor; avoid volume depletion.
• Atrial fibrillation: rate or rhythm control and anticoagulation.

Interventional and surgical

• Surgical repair (annuloplasty ring) at the time of left sided valve surgery for severe TR, or moderate TR with annulus 40 mm or more (21 mm/m2) or right heart failure.
• Isolated severe symptomatic TR without severe right ventricular dysfunction or pulmonary hypertension: surgery (repair preferred, replacement with bioprosthesis), operative mortality 8 to 10% (higher if late).
• Transcatheter tricuspid edge to edge repair (TriClip; TRILUMINATE improved quality of life), transcatheter valve replacement (EVOQUE), or caval valve implantation for inoperable patients.
• Endocarditis: antibiotics, early surgery or percutaneous aspiration for persistent vegetations in injection drug users, avoid valvectomy if possible.
• Lead related TR: lead extraction or repositioning; leadless pacing.
• Echo follow up every 6 to 12 months for severe TR.