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Indications for Tricuspid Valve Intervention
Tricuspid valve (TV) surgery has one of the highest morbidity and mortality rates of all cardiac surgical procedures. , This is not necessarily because TV repair (TVr) or TV replacement (TVR) is particularly difficult technically, but rather because the presence of tricuspid regurgitation (TR) often reflects advanced cardiac disease, right ventricular (RV) dysfunction, chronic heart failure, and generally poor functional state.
The evolution of two- and three-dimensional (2D and 3D, respectively) intraoperative transesophageal echocardiography (TEE) over the past two decades has enabled routine and comprehensive evaluation of the TV and consideration for intervention at the time of surgery for left-sided valvular disorders. In that context, conventional wisdom is that TVr adds little to the overall risk of the procedure. Consequently, attitudes have been shifting toward considering TV surgery for less than severe TR or even toward prophylactic interventions on valves with a high potential for future dysfunction.
A recent analysis of more than 88,000 cases in the Society of Thoracic Surgeons (STS) database by Badhwar and colleagues revealed that between 2011 and 2014, TVr was performed in 14.3% of all mitral valve (MV) repair or replacement surgeries: 3.5% of patients with none to mild TR, 30.6% with moderate TR, and 75.6% with severe TR. These authors reported that adding a TVr to MV surgery with or without coronary bypass grafting (CABG) was associated with an increased morbidity rate, including ventilation longer than 24 hours, renal failure, stroke, deep sternal wound infection, and reoperation, but not 30-day mortality rate. They also noted that the frequency of patients requiring a permanent pacemaker after isolated MV surgery was 6.2%, and this increased to 14.5% when TVr was added to the procedure. This report suggests that there may be tangible morbidity risks associated with adding a TV procedure on to a left-sided valve procedure.
Most TR is functional , as a result of leaflet tethering and annular dilatation from RV remodeling in patients with left-sided ventricular or valvular disease ( Fig. 104.1 and , 
).
Functional tricuspid regurgitation (TR). Transesophageal echocardiographic midesophageal four-chamber view demonstrating tricuspid valve leaflet tethering ( A ) from the annulus (yellow line) toward the right ventricular apex (red line) , leading to functional TR ( B ). P, Posterior leaflet; S, septal leaflet. (See accompanying ,
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Video 104.1. A and B, Functional tricuspid regurgitation (TR). Transesophageal echocardiographic midesophageal, four-chamber views demonstrating tricuspid valve leaflet tethering from the annulus toward the right ventricular apex consistent with functional TR.
Table 104.1 compares the latest American College of Cardiology/American Heart Association (AHA/ACC) and European Society of Cardiology (ESC) guidelines for the management of TR in various clinical situations. , The decision of whether and when to recommend a TVr depends on the patient’s symptoms, severity of TR, RV function, size of the annulus, and presence of pulmonary hypertension (PH) or atrial fibrillation. ,
TABLE 104.1
Comparison of American College of Cardiology (ACC)/American Heart Association Guidelines (AHA) and European Society of Cardiology (ESC) Guidelines
| AHA/ACC 2014 | ESC 2012 | |
|---|---|---|
| Isolated Tricuspid Valve Surgery (Primary) | ||
| Symptomatic severe TR unresponsive to medical therapy | Class IIa | Class I a |
| Asymptomatic severe TR with RV dilatation or dysfunction | Class IIb | Class II |
| Reoperation (after left-sided procedure) for severe symptomatic TR | Class IIb | Class IIa |
| Tricuspid Valve Surgery with Concomitant Left-Sided Surgery (Secondary) | ||
| Severe TR at the time of MV surgery (regardless of symptoms) | Class I | Class I |
| Mild or moderate, primary or secondary TR | ||
| Regardless of other considerations | No mention | Class IIa |
| With TV annular dilatation | Class IIa | Class IIa b |
| PH without annular dilatation | Class IIb | Class IIa b |
MV, Mitral valve; PH, pulmonary hypertension; TR, tricuspid regurgitation.
a Without severe right ventricular (RV) dysfunction.
b This level of recommendation is not explicitly mentioned in the ESC guidelines, but it is implied by the comment “regardless of other considerations.”
Severity of Tricuspid Regurgitation
The severity of functional TR graded by echocardiography can be influenced by RV preload, afterload, and contractile state, all of which may be significantly affected by general anesthesia and positive-pressure ventilation. Thus, functional TR severity can change acutely and repeatedly during the course of cardiac surgery. The ACC/AHA and ESC universally recognize severe TR as an indication for TVr at the time of MV surgery (class I indication). The addition of a corrective TV procedure to the planned MV procedure is associated with a relatively significant long-term clinical benefit. In a recent meta-analysis of 15 studies including 2840 patients, Pagnesi and colleagues reported that the addition of TV surgery to mitral or aortic valve surgery was associated with a significant decrease in the risk of cardiac-related mortality at a mean follow-up of 6 years (odds ratio [OR], 0.38). The addition of TVr also resulted in a lower risk of developing more than moderate TR (OR, 0.16). Most of the studies included in this meta-analysis were observational. In another retrospective analysis of nearly 24,000 patients between 1990 and 2014, Kelly and colleagues found a correlation between the severity of TR diagnosed by intraoperative preprocedural TEE and postcardiac surgical mortality rate for all cardiac surgical procedures. When adjusted for confounders, moderate TR (hazard ratio [HR], 1.24) and severe TR (HR, 2.02) were associated with an increased risk of mortality. On the other hand, patients who underwent TV surgery had a statistically lower chance of death regardless of the grade of TR (HR, 0.74).
The ACC/AHA and ESC guidelines are less committed to providing recommendations on valve repair for severe TR in the context of procedures that do not involve an open cardiotomy, such as CABG. In the case of symptomatic TR associated with RV failure and liver congestion, the ESC guidelines recommend TVr as a class I indication, whereas this is considered a class IIa indication in the ACC/AHA guidelines. When less than severe TR is present, the decision to repair the TV is even more controversial and depends on the presence of other factors such as RV dysfunction or annular dilatation.
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