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Anatomy of the normal tricuspid valve showing orientation of the leaflets and surrounding structures (A) and the outward dilation of the annulus toward the RV-free wall (B) (modified version of the original reprinted with permission from Dreyfus et al. 50 ).
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Tricuspid regurgitation (TR) is the most common lesion of the tricuspid valve (TV). Mild TR is common and usually is benign. However, moderate or severe TR can lead to irreversible myocardial damage and adverse outcomes. Despite these findings, few patients with significant TR undergo surgery. The treatment of functional (secondary) TR in particula...
Context in source publication
Context 1
... TV orifice is the largest of the four heart valves and is semilunar in shape (Figure 1). It consists of three leaflets (anterior, septal, and posterior) that insert into a true fibrous annulus and are separated by three commissures: anteroseptal, posteroseptal, and anteropos- terior. The leaflets are connected by chordae tendinae to three pap- illary muscles (although multiple papillary muscles may be present). In contrast to the mitral valve, each leaflet of the TV is only connected to a single papillary muscle. The size of the leaflets varies with the anterior being largest and the septal smallest. The annulus is dynamic and changes shape throughout the cardiac cycle. Its diam- eter is typically 30 -35 mm, and is related to body size. Thus, the average indexed diameter is 21 mm/m 2 . As the septal portion of the annulus is fixed, dilatation of the annulus occurs primarily at the free wall. For this reason, annular sizing for TV repair is based on the size of the base of the septal leaflet. 7 The annulus is non- planar and oval, and annuloplasty rings are appropriately shaped to cope with TV-specific anatomy. The conduction system is close to the tricuspid annulus leading to a high rate of post-operative pacemaker implantation (11.6%). 6 The rate is significantly higher after replacement compared with repair (17.2 vs. 9.5%; P ¼ ...
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To the Editor, Over the last few years we have become aware of the adverse impact of tricuspid regurgitation on morbidity (worse quality of life, hospital admissions…) and mortality with the corresponding increase in the number of interventions performed on the tricuspid valve both surgically and percutaneously.1,2 From the surgical point of view,...
Purpose of Review
This review aims to provide an updated overview and a clinical perspective on novel transcatheter tricuspid valve interventions (TTVI), highlighting potential challenges and future directions.
Recent Findings
Severe tricuspid regurgitation (TR) is a predictor of mortality. However, a sizeable number of patients remain untreated u...
The tricuspid valve (TV) and right ventricle (RV) are a complex mechanical system. Tricuspid regurgitation impacts a growing and heterogeneous population, leading to right-sided volume overload and right heart failure if left untreated. In part because isolated surgical tricuspid valve repair (TVR) is performed infrequently and has a high mortality...
Background:
The aim of this study was to evaluate the clinical outcomes of tricuspid valve repair using aortic cross-clamping versus using beating heart surgery.
Methods:
A total of 208 patients (67 males, 141 females; mean age 61.5±9.2 years; range, 29 to 81 years) who underwent concomitant cardiac surgery and tricuspid valve repair between Jan...
Objective
The primary aim was to investigate the role of underlying heart disease on preoperative NT-proBNP levels in patients admitted for adult cardiac surgery, after adjusting for the known confounders age, gender, obesity and renal function. The second aim was to investigate the predictive value of preoperative NT-proBNP with regard to severe p...
Citations
... Tricuspid regurgitation (TR) is a valvular heart condition affecting 65 -85% of the population globally 1,2 . Based on the underlying mechanism, we can distinguish three types of TR, primary/or organic TR (due to the direct involvement of the tricuspid valve), secondary/or functional TR (resulting from right-sided heart remodeling) 3,4 , and more recently, isolated TR (atrial fibrillation being the dominant cause) is now being recognized as a distinct entity and is explained as TR without left-sided heart lesions 4 . The secondary TR accounts for the most frequent mechanism of TR. ...
... However, due to the shorter lifespan of patients with FTR and timing limitations, FTR is still commonly treated simultaneously with left-sided heart valve surgery [14]. Despite its effectiveness, surgical treatments for FTR have limitations, including the possibility of recurrence in the medium to long term after surgery [15]. ...
... Echocardiography is the basic imaging modality in the assessment of the mechanism and severity of TR [3][4][5][6]. Presence of severe TR affects the morbidity and has been previously reported as a strong negative predictor of long-term survival in a general population. Recent advances in both pharmacotherapy and transcatheter treatment techniques led to the reduction of mortality in a variety of cardiac conditions such as heart failure or VHD, however, its influence on the prognosis in an unselected population of TR patients in a real-life setting has not been fully elucidated. ...
Introduction:
Tricuspid regurgitation (TR) is a common acquired valvular heart disease. Recently new transcatheter treatment options for severe TR have emerged that could change the management of this condition, which warrants better characterization of this specific patient group.
Objectives:
The aim of the study was to describe the clinical and echocardiographic characteristics of patients with severe TR and to evaluate their short- and mid-term prognosis.
Patients and methods:
This retrospective, observational single-center study enrolled consecutive patients with severe TR hospitalized between January 2016 and September 2021 in the 1st Chair and Department of Cardiology, Medical University of Warsaw, Poland. The severity of heart failure (HF) was evaluated using New York Heart Association (NYHA) classification. Echocardiographic assessment was performed by experienced sonographer. EuroSCORE II and TRI-SCORE were computed for each patient. 12- and 24-month clinical outcomes were reported.
Results:
There were 172 patients [93 female (54.1%)] included. The mean age was 76.4 (± 10.5) years. The most common comorbidities included: atrial fibrillation (84.9%), hypertension (68.0%), chronic kidney disease (54.1%), coronary artery disease (45.3%), diabetes mellitus (30.9%). The median EuroSCORE II and TRI-SCORE values were 4.68% and 14.0%, respectively. The median follow-up was 24 months. The overall mortality was 29.7% at 1 year and 47.3% at 2 years. TR grade, TAPSE <17 mm, TAPSE/SPAP <0.26 and right atrial area were significant factors associated with mortality.
Conclusions:
Patients presenting with severe TR are characterized by a large comorbidity burden and poor prognosis, despite intensive heart failure management.
... Transthoracic echocardiography (TTE) is the gold standard for evaluating and grading the severity of TR. 17,18 The American Heart Association/American College of Cardiology (AHA/ACC), American Society of Echocardiography, and the European Society of Cardiology provide diagnostic criteria. 17 19 Color flow Doppler is used to grade TR severity ( Figure 2). ...
... Transthoracic echocardiography (TTE) is the gold standard for evaluating and grading the severity of TR. 17,18 The American Heart Association/American College of Cardiology (AHA/ACC), American Society of Echocardiography, and the European Society of Cardiology provide diagnostic criteria. 17 19 Color flow Doppler is used to grade TR severity ( Figure 2). Transesophageal echocardiogram is limited by offangles and a further distance to the probe resulting in suboptimal images under certain pathologic circumstances. ...
Tricuspid regurgitation is a common yet clinically complex problem, traditionally managed with diuretic therapy with no observable mortality benefit. Older studies on surgical intervention observed poor outcomes; however, this clinical reasoning predates current surgical approaches and novel transcatheter technology. The tricuspid apparatus is a complex structure that poses a technical challenge for surgeons and interventional cardiologists. Recent advances in surgical techniques and transcatheter therapy, particularly edge‐to‐edge repair devices, have demonstrated promising results for safety, reduction in tricuspid regurgitation, and improving quality of life. We review the clinical, imaging, and hemodynamic findings that characterize patients who should be considered for intervention, alongside the rapidly evolving approaches to interventional management.
... The organic (primary) aetiology of tricuspid regurgitation (TR) is reported in a fairly small percentage of patients (8-10%). 1,2 Nonetheless, this percentage may not entirely reflect reality, since the diagnosis of organic TR requires a correct assessment of the anatomy of the tricuspid valve, which is not always possible with the conventional two-dimensional echocardiography. ...
Background
Tricuspid valve agenesis (TVA) is an exceptionally rare congenital cardiac disease characterized by the incomplete formation or complete absence of one or more tricuspid leaflets. It is commonly diagnosed during childhood due to the development of heart failure symptoms.
Case summary
We report the case of 62-year-old women admitted for worsening of heart failure symptoms (New York Heart Association functional class IV at admission). Standard transthoracic echocardiogram was performed and showed severe right heart dilatation and severe tricuspid regurgitation. Three-dimensional echocardiogram revealed the absence of the posterior tricuspid leaflet. The patient underwent an uncomplicated surgical bioprosthetic valve replacement with a favorable outcome and partial recovery of right ventricular function. In our case, valve repair was not favored due to the additional mild hypoplasia of the anterior leaflet. The 3-month postoperative evolution of the patient was favorable, with significant symptom relief.
Discussion
The diagnosis of tricuspid agenesis during adulthood is uniquely uncommon. Three-dimensional echocardiography can provide accurate preprocedural insight into the valve anatomy, allowing to plan for either valve repair when the anatomy is suitable or valve replacement.
... 17 Moderate to severe TR was graded using the echocardiographic criteria of the 2017 European Society of Cardiology. 18 A group with a peak TR velocity of ≥3.4 m/s is considered to have a high probability of pulmonary hypertension according to a 2015 European Society of Cardiology review article. 19 IVC plethora is defined as a <50% decrease in the IVC diameter after a deep inspiration, and it suggests increased right atrial pressure and a chance of hepatic congestion. ...
Background
There are limited data on the efficacy and safety of direct oral anticoagulants (DOACs) in patients with atrial fibrillation with significant tricuspid regurgitation (TR), which can lead to hepatic dysfunction and intestinal malabsorption. We aimed to compare the efficacy and safety of DOACs and warfarin for patients with atrial fibrillation with significant (moderate to severe) TR.
Methods and Results
A total of 1215 patients with significant TR and atrial fibrillation who were treated with warfarin (N=491) or DOACs (N=724) were retrospectively analyzed. The primary outcomes were ischemic stroke, systemic embolic events, and hospitalization for major bleeding. The secondary outcomes were intracranial hemorrhage, hospitalization for gastrointestinal bleeding, all‐cause mortality, and a composite outcome. The median follow‐up duration was 2.4 years. In the inverse probability treatment weighting–adjusted cohort, DOACs and warfarin had a similar risk for ischemic stroke and systemic embolic events (adjusted hazard ratio [aHR], 0.95 [95% CI, 0.67–1.36]; P =0.79) and major bleeding (aHR, 0.78 [95% CI, 0.57–1.06]; P =0.11). For the secondary outcomes, relative to warfarin, DOACs had a lower risk of intracranial hemorrhage and the composite outcome, and a comparable risk for gastrointestinal bleeding and all‐cause mortality. In the subgroup analysis, the effects of DOACs on ischemic stroke and systemic embolic events were comparable to the effects of warfarin, even in patients with inferior vena cava plethora (increased right atrial pressure) or severe TR.
Conclusions
In this study, relative to warfarin, DOACs demonstrated comparable efficacy for ischemic stroke and systemic embolic events and major bleeding, with a lower intracranial hemorrhage risk in patients with significant TR and atrial fibrillation, indicating their effectiveness and safety.
... Secondary TR leads to inadequate coaptation between the tricuspid leaflets. 111,112 TR is rarely isolated and is quite prevalent in association with other VHDs. 113 In addition, multiple studies have noted the higher prevalence of TR in women compared to men in the general population, especially in the community setting, even though this difference may be reduced in the tertiary-care setting. ...
Valvular heart diseases (VHDs) are a major cause of cardiovascular morbidity and mortality worldwide. As degenerative and functional mechanisms represent the main etiologies in high-income countries are degenerative and functional, while in low income countries etiologie is mostly rheumatic. Although therapeutic options have evolved considerably in recent years, women are consistently diagnosed at later stages of their disease, are delayed in receiving surgical referrals, and exhibit worse postoperative outcomes, compared to men. This difference is a result of the historical underrepresentation of women in studies from which current guidelines were developed. However, in recent years, important research, including more female patients, has been conducted and has highlighted substantial sex-specific differences in the etiology, diagnosis, and treatment of VHDs. Systematic consideration of these sex-specific differences in VHD patients is crucial for providing equitable healthcare and optimizing clinical outcomes in both female and male patients. Hence, this review aims to explore implications of sex-specific particularities for diagnosis, treatment options, and outcomes in women with VHDs.
... Several studies have examined the advantages of tricuspid valve repair or replacement in symptomatic patients with TR after HTx and have demonstrated lower mortality rates and improved quality of life following surgical intervention compared to medical treatment [53,54]. When there are no structural defects in the valve, TVP through annuloplasty is considered preferable over replacement [9,55], while in cases of HTx with significant structural defects in the leaflets, TVR is the preferred therapeutic approach [28]. ...
Tricuspid regurgitation (TR) is the most common valvular pathology after heart transplantation (HTx) and endomyocardial biopsy (EMB) remains responsible for the majority of cases due to the high probability of structural valve damage. The aim of the present review was to describe the results of surgical management of severe tricuspid regurgitation through tricuspid valve replacement (TVR) after a previous HTx. A systematic review was conducted by searching Pubmed, ScienceDirect, SciELO, DOAJ, and Cochrane databases until June 2023 for publications reporting patients undergoing TVR surgery after a previous HTx. If no right heart valve surgery was undertaken, or a heterotopic heart transplant was performed, or if the concomitant procedure was performed during the transplant itself, the paper was excluded. Twenty articles met our inclusion criteria out of 1532 potentially eligible studies, with a total of 300 patients. Mean age was 55.1 ± 9.6 years, and 85.1% were male. The mean number of EMB per patient was 31.1 ± 5.5 with a mean time between HTx and TVR of 7.64 ± 3.31 years. Bioprostheses were used in 83.3% of cases and 75.0% of patients with a bioprosthesis were reported as alive at last follow-up. Tricuspid valve repair is a valuable option, but these patients will be susceptible to recurrent TR after EMB. TVR with a bioprosthesis may provide the optimal solution for this subset of patients, as EMB is not feasible with a mechanical valve.
... When TR occurs, TV loses its normal shape and dilates under the strain of the dilated RA and RV. Recent studies suggest that overloading of the RV caused by long-term TR may lead to irreversible myocardial injury of the RV (17). ...
... Additional studies have shown that electrical factors, such as delayed excitation of the RV, geometric changes in the RV, or mechanical dyssynchronization, may also cause TR (15,22). As a result, as the focus of LITR has increased, the amount of TV surgery has increased (17). Most studies have reported incomplete reduction of TR (23). ...
Background:
Lead-induced tricuspid regurgitation is one of the complications after permanent pacemaker implantation (PPI) and refers to tricuspid regurgitation (TR) caused by the lead in the right ventricle (RV).
Objectives:
To study the clinical characteristics of severe TR after PPI and the effect of transcatheter tricuspid valve replacement (TTVR) with the guidance of 3-dimensional (3D) printing.
Methods:
This study was a single-center, descriptive study. Six patients with severe TR after PPI were enrolled in Xijing Hospital from January 2020 to May 2020. Before TTVR, the 3D printed tricuspid valve (TV) model was used for evaluation in the bench test. LuX-Valve was implanted under the guidance of TEE and x-ray fluoroscopy, and all patients underwent transatrial access. Six patients' data were collected at baseline, before discharge, and 6 months, 1 year and 2 years after TTVR.
Results:
The LuX-Valve was successfully implanted in 6 patients, TR was significantly reduced to ≤2+, and no deaths or cardiopulmonary bypass occurred during procedures. Three cases were caused by TV expansion: Patient #4 had TR caused by lead adhesion to TV, Patient #2 had TR caused by lead winding, and Patient #6 had TR caused by lead impingement on TV. During the 2-year follow-up, TTE revealed that 5 patients had no/trace regurgitation, and one patient (Patient #5) had mild regurgitation. All 6 patients (100.0%) reached primary endpoints.
Conclusion:
TTVR guided by 3D printing is safe and effective in the treatment of severe TR associated with permanent pacemaker lead, providing prospects and possibilities for the precise treatment of TV-related diseases.Clinical Trial Registration: ClinicalTrials.gov Protocol Registration System (NCT02917980).
... Studies reviewing the benefits of tricuspid valve repair or replacement in all symptomatic patients with TVR showed lower mortality and better quality of life after operation compared with medical treatment. 30,31 Tricuspid valve repair via annuloplasty is deemed favorable compared with replacement when no structural defect of the valve is present. [32][33][34] Ring annuloplasty has been shown to be superior to De Vega annuloplasty because the rate of recurrence of TR is significantly higher after De Vega technique as the annulus dilates in longterm follow-up. ...
Unlabelled:
Tricuspid valve regurgitation (TVR) is often observed after orthotopic heart transplantation. However, there is a scarcity of data regarding long-term outcomes of patients with TVR.
Methods:
Between January 2008 and December 2015, 169 patients underwent orthotopic heart transplantation at our center and were included in this study. TVR trends and associated clinical parameters were retrospectively analyzed. TVR was assessed after 30 d, 1 y, 3 y, and 5 y, and groups were defined according to changes in TVR grade: constant (group 1; n = 100), improvement (group 2; n = 26), and deterioration (group 3; n = 43). Survival, outcome with regard to operative technique, and long-term kidney and liver function during follow-up were assessed.
Results:
Mean follow-up time was 7.67 ± 4.17 y (median 8.62, Q1 5.06, Q3 11.16). Overall mortality was 42.0%, with differences between the groups (P < 0.01). Cox regression analysis revealed improvement of TVR as a significant predictor for survival (hazard ratio 0.23; 95% confidence interval, 0.08-0.63, P < 0.01). After 1 y 2.7%, after 3 y 3.7%, and after 5 y 3.9% of the patients showed persistent severe TVR. Creatinine levels after 30 d and 1, 3, and 5 y showed significant differences between the groups (P = 0.02, P < 0.01, P < 0.01, and P = 0.01), deterioration of TVR being associated with higher creatinine levels during follow-up.
Conclusions:
Deterioration of TVR is associated with higher mortality and renal dysfunction. Improvement of TVR may function as a positive predictor for long-term survival after heart transplantation. Improvement of TVR should be a therapeutic goal offering a prognostic value for long-term survival.
