2024 Insuficiencia Tricuspidea

Canadian Journal of Cardiology 40 (2024) 185e200
Review
Contemporary Approach to Tricuspid Regurgitation:
Knowns, Unknowns, and Future Challenges
Daryoush Samim, MD,a Chrisoula Dernektsi,a Nicolas Brugger, MD,a David Reineke, MD,b and
Fabien Praz, MDa
a
Department of Cardiology, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
b
Department of Cardiac Surgery, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
ABSTRACT
RESUM
E
Severe tricuspid regurgitation (TR) worsens heart failure and is asso- La regurgitation tricuspidienne sevère aggrave l’insuffisance cardiaque
ciated with impaired survival. In daily clinical practice, patients are et est associe e à une diminution de la survie. En pratique clinique
referred late, and tricuspid valve interventions (surgical or trans- courante, les patients sont oriente s tardivement vers les soins
catheter) are underutilised, which may lead to irreversible right ven- specialise
s. Les interventions valvulaires tricuspides (chirurgicales ou
tricular damage and increases risk. This article addresses the par cathe ter) sont sous-utilise
es, ce qui mène à des le sions ventricu-
appropriate timing and modality for an intervention (surgical or versibles et à un risque accru. Cet article traite du
laires droites irre
https://doi.org/10.1016/j.cjca.2023.11.041
0828-282X/Ó 2023 The Authors. Published by Elsevier Inc. on behalf of the Canadian Cardiovascular Society. This is an open access article under the CC BY
license (http://creativecommons.org/licenses/by/4.0/).
Descargado para Anonymous User (n/a) en University Hospital October 12th de ClinicalKey.es por Elsevier en mayo 27, 2024. Para uso
personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2024. Elsevier Inc. Todos los derechos reservados.
186 Canadian Journal of Cardiology
Volume 40 2024
transcatheter), and its potential benefits on clinical outcomes. Ongoing moment approprie pour re
aliser une intervention (chirurgicale ou par
randomised controlled trials will provide further insights into the effi- ter), des modalite
cathe s ainsi que des bienfaits possibles sur le pro-
cacy of transcatheter valve interventions compared with medical nostic clinique. Les essais randomises en cours fourniront plus d’in-
treatment. formation sur l’efficacite des interventions valvulaires par cathe ter
comparativement au traitement me dical.
Epidemiology to the TV annulus.22 The diagnosis can be made non-

Tricuspid regurgitation (TR) is one of the most common invasively with 2-dimensional transthoracic echocardiography
valvular heart diseases after mitral regurgitation. TR of any or transesophageal echocardiography (TEE), but further un-
severity is present in more than 65% of the general popula- derstanding of TR mechanism usually requires the use of
tion.1,2 Population-based studies have suggested that clinically advanced imaging techniques such as 3-dimensional (3D)
significant TR (moderate or higher grade) is found in 0.55% echocardiography23 or computed tomography (CT) to estab-
of patients, increasing with age and reaching 6.6% in those > lish the exact interaction between the TV and the lead.24 A
75 years old, a prevalence similar to that of aortic stenosis in prospective registry showed that TEE-guided lead implanta-
this age category.3,4 Women are affected more frequently than tion (for pacemaker or implantable cardioverter-defibrillator)
men,5 and female sex is an independent predictor of TR was associated with less TR worsening compared with con-
severity and progression.6-8 Hypotheses to explain these sex ventional placement.25 However, systematic implementation
differences include the higher prevalence of heart failure (HF) of echocardiographic guiding seems difficult for procedures
with preserved ejection fraction and atrial fibrillation (AF) in usually performed under local anaesthesia.
women.9 Other clinical predictors of severity and progression Primary TR is uncommon, especially in developed coun-
of TR include older age, left ventricular dysfunction, AF, pre- tries, accounting for 5% to 10%1 of all TR, and is associated
and post-capillary pulmonary hypertension,7 previous cardiac with organic leaflet lesions or anomalies. Usually, primary TR
surgery,10 and the presence of a cardiac implantable electronic is observed in Barlow’s disease, congenital heart disease
device (CIED) lead.8 (Ebstein anomaly, double-orifice TV or TV dysplasia, hypo-
Causes and Classification plasia, or cleft), trauma (chest wall trauma or endomyocardial
The classification of TR has recently evolved beyond the biopsy), carcinoid syndrome, endomyocardial fibrosis, or
traditional subdivision into primary and secondary disorders underlying infectious disease (endocarditis).
(Fig. 1).11-13 The current classification scheme reflects a
better understanding of the various TR mechanisms and
their outcomes.14 Secondary TR is the most frequent form
(> 80%) and subdivision into atrial and ventricular etiol- Challenges of TV Imaging and Treatment
ogies has been proposed. In ventricular secondary TR, the The TV apparatus anatomy is complex and its precise
right ventricle (RV) is dilated (infra-annular) and the leaf- evaluation is key when planning TV interventions. Despite its
lets are tethered, whereas in atrial secondary TR a pre- name, the TV was found to be truly tricuspid in fewer than
dominant annular dilation is observed and leaflet tenting is 60% of the subjects studied in a series of autopsied patients.26
almost absent. Diagnostic parameters differentiating atrial This was confirmed in vivo in a multinational retrospective
from ventricular secondary TR have been recently proposed study analysing TV morphologies with the use of TEE that
by the Tricuspid Valve Academic Research Consortium showed a 4-leaflet anatomy in 39% of the patients (Fig. 2).27
(TVARC) and the PCR Tricuspid Focus Group and are Imaging is key to assess the TV, and transcatheter pro-
listed in Table 1.15 Secondary TR is most frequently related cedures become challenging when the transgastric short axis
to left-side valvular heart disease or left ventricular and the deep/mid esophageal RV inflow/outflow views are of
dysfunction, and pre- or post-capillary pulmonary hyper- insufficient quality.28 The anterior location of the TV, along
tension (PHT).3,16,17 In addition, CIED leaderelated TR with right heart dilation, increases the distance between the
is an increasing distinct entity that represents 10%-15% of esophagus and the right heart. Acoustic shadowing due to left-
all TR and requires specific diagnostic work-up and side cardiac prostheses, lipomatosis of the interatrial septum,
management.13 and the delivery system itself are other factors potentially
About 10% to 33% of patients develop or worsen TR after limiting TEE image quality.
implantation of a CIED RV lead.13,18-20 Interestingly, a Four important structures are located in immediate
leadless pacemaker may also affect tricuspid valve (TV) proximity to the TV and can be damaged during TV in-
function,21 particularly when deployed into the septum close terventions: the conduction system (atrioventricular node
and right bundle of His), the right coronary artery, the
noncoronary sinus of Valsalva, and the coronary sinus
ostium (Fig. 2). Furthermore, the lack of calcium, the
Received for publication September 20, 2023. Accepted November 29, 2023.
angulation in relation to the inferior vena cava, the anatomic
Corresponding author: Dr Daryoush Samim, Department of Cardiology, variability of the subvalvular apparatus, the trabeculated and
Bern University Hospital, Freiburgstrasse 20, Bern, Switzerland. Tel.: þ41 31
66 4 16 75. thin RV wall complicating anchoring, and the interaction
E-mail: daryoush.samim@insel.ch with a preexisting CIED lead are additional limitations for
See page 197 for disclosure information. interventions.29
Samim et al. 187
Contemporary Approach of Tricuspid Regurgitation
Figure 1. Novel classification of TR based on disease mechanism. HFpEF, heart failure with preserved ejection fraction; CIED, cardiac implantable
electronic device; RA, right atrium; RV, right ventricle.
TR undertreatment still represents one of the main chal- untreated symptomatic severe aortic stenosis.34 Despite
lenges and is explained by several factors. First, the miscon- comparable prevalence and impact on clinical outcomes,2 se-
ception that TR resolves after left-side interventions is still a vere TR is less frequently regarded as a factor affecting prog-
prevalent opinion, even though contradicted by the available nosis and contributing to HF symptoms.
evidence. Second, TR severity is frequently underestimated, Although TR mechanism (CIED-related, primary or sec-
and therefore referral occurs late, when irreversible RV ondary TR) does not appear to be a discriminant of outcomes
dysfunction already increases the surgical risk. In a recent at 5 years,35 atrial and ventricular secondary TR have a clearly
cohort study by our group, only about 10% of the patients distinct prognosis, with lower risk of death or HF hospital-
with severe TR underwent an intervention of any kind (either isation for patients with atrial secondary TR (78% vs
surgical or transcatheter) during a follow-up period of 4 46%).36,37 In addition to TR etiology, TR severity, age, severe
years.30 renal failure, left ventricular dysfunction, PHT, and RV
dysfunction all predict death in patients with severe TR.30,38
Recently, a machine-learning algorithm was used to classify
Impact of TR on Prognosis patients with severe TR into 4 different “phenoclusters” with
Severe TR is associated with excess mortality and distinct outcomes in terms of death or HF hospitalisation.35
morbidity. Cumulative mortality of conservatively managed Discriminating variables were age, albumin, blood urea ni-
severe TR is w40%, w50%, and w70% at 1-, 2- and 4-year trogen, RV function, and systolic blood pressure.35 This
follow-up, respectively.6,30-33 This roughly corresponds to emphasises the fact, that beyond cardiac damages and valve
Volume 40 2024
Table 1. Proposed main criteria for the diagnosis of atrial and grading, cardiovascular magnetic resonance imaging should be
ventricular secondary tricuspid regurgitation considered, because its prognostic value (regurgitant fraction
Atrial Ventricular > 45%) has been established in patients with severe secondary
Leaflet morphology TR.45 CT has a fundamental role for the planning of trans-
Tenting height (4Ch) mm 9 >9 catheter annuloplasty and replacement procedures.44 Assess-
Right heart chamber size ment of the tricuspid annulus dimensions and morphology,
RV midventricular diameter, mm 38 > 38 localisation of the right coronary artery, and its distance from
End-systolic RA:RV area ratio 1.5 < 1.5
RV systolic function
the tricuspid annulus represent some of the essential infor-
TAPSE, mm > 17 17 mation provided by CT imaging.46,47
FAC, % 35 < 35
RV FWS, % 20 < 20
RV TDI S0 , cm/s 9 <9 Timing of Interventions: Assessment of Risk
3D RVEF, % 50 < 50
LVEF, % 50 Variable and RV Function
Invasive pulmonary vascular Delayed surgical treatment of patients with symptomatic
hemodynamics severe TR contributes to the high morbidity and mortality
PCWP, mm Hg 15 Variable rate observed after isolated surgical TV replacement.48-51
mPAP, mm Hg < 20 Usually > 20
PVR, Wood units < 2.0 Variable
According to historical data including late referral and pa-
tients operated for infective endocarditis, the risk of in-
Adapted from Hahn et al.15 under Creative Commons Attribution- hospital mortality is w 10% after isolated TV sur-
NonCommercial-NoDerivs 4.0 International (CC BY-NC-ND 4.0 DEED)
gery.48,49,52,53 Furthermore, about two-third of the patients
license.
3-dimensional; 4Ch, 4-chamber view; FAC, fractional area change; FWS,
experience at least 1 complication and almost 20% suffer from
free wall strain; LV, left ventricular; LVEF, left ventricular ejection fraction; a major adverse event after isolated TV surgery.48 Therefore,
mPAP, mean pulmonary artery pressure; PCWP, pulmonary capillary wedge appropriate timing of intervention is crucial to avoid irre-
pressure; PVR, pulmonary vascular resistance; RA, right atrial; RV, right versible RV damage and organ failure (Table 2; Figs. 3 and 4).
ventricular; RVEF, right ventricular ejection fraction; TAPSE, tricuspid A recent single-centre study in the United States including
annular plane systolic excursion; TDI S0 , tissue Doppler imaging tricuspid 159 patients (57.2% female) who underwent isolated
annular velocity. tricuspid surgery from 2004 to 2018 (mean follow-up of 5.1
4.0 years) compared outcomes according to the timing of
surgery (115 operated when class I indication was reached, 44
anatomy, clinical factors also need to be taken into consid- operated earlier). Early surgery before reaching class I indi-
eration when evaluating patients with severe TR. cation in patients with severe TR decreased operative mor-
tality (0.0% vs 7.0%; P ¼ 0.107) and adverse events (18.2%
vs 35.7%; P ¼ 0.036).54
Severity Grading and Multimodality Imaging Because usual risk scores have not been validated for TV
Grading of TR severity is mainly based on the vena con- surgery, the dedicated TRISCORE based on clinical factors
tracta and the effective regurgitant orifice area, which was has been recently proposed and was shown to outperform the
shown to continuously affect mortality with an exponential STS-PROM and EuroScore/EuroScore II for the prediction of
risk increase even beyond the traditional cutoff of 40 mm2.39 events after both isolated55 and redo56 TV surgery. In an
For this reason, as well as for the purpose of device selection international multicentre registry, patients with low ( 3) and
and result evaluation, a 5-grade scheme has been pro- intermediate4,5 TRISCORE derived a mortality benefit from
posed.40,41 Several cohort studies have shown the incremental successful TR treatment (any modalities) at 2 years, whereas
prognostic value of this 5-grade scheme, with higher mortal- no significant difference was found in those with higher score
ity, HF hospitalisation, and poorer hemodynamics in patients ( 6).57 The Model for End-Stage Liver Disease (MELD)
with “massive” or “torrential” TR.30,42,43 Although this clas- score initially developed to assess liver dysfunction also pre-
sification may be useful for device selection (decision for repair dicts mortality in patients undergoing TV surgery (either
vs replacement), patients should be evaluated for treatment isolated or concomitant) and might be used as an alternative
before they reach more than severe TR. indicator of the risk of mortality.58,59
Reproducible grading is challenging, because TR severity In addition to scoring, assessment of concomitant cardiac
varies according to loading conditions and respiratory- damage in patients with significant TR based on the presence
dependent RV filling. Qualitative and semiquantitative eval- of RV dysfunction and the burden of right-side HF symp-
uation can be limited by the low jet velocity (or even laminar toms, identifies candidates with worse long-term outcomes
flow) that influences its visualisation with the use of Doppler treated either conservatively60 or surgically.61 Surgical in-
echocardiography.44 Furthermore, multiple limitations of the terventions should therefore be performed early, as soon as
proximal isovelocity surface area (PISA) methodology to there is evidence of RV dilation or declining RV function.62,63
quantify TR should be acknowledged: the complex PISA The recently published TVARC document15 attempts to
surface (hemiellipsoid or even stellar rather than hemispheri- define cutoffs indicative of RV dysfunction severity (Table 3).
cal), the high variability during the cardiac cycle, and the Although these values may provide some guidance, they
nonplanar surface of the regurgitant orifice (which may should be considered with caution, because the assessment of
require a correction for the leaflet angle). Therefore, the PISA RV function in patients with severe TR by means of load-
method typically underestimates the true orifice, particularly dependent parameters may be unreliable and should not
in secondary TR, by a factor close to 50%.44 To confirm TR preclude access to a procedure.
Samim et al. 189
Figure 2. Challenges of tricuspid valve assessment and treatment. The x-axis represents the dedicated step-by-step work-up of a patient with
tricuspid regurgitation, and the y-axis highlights the increasing degree of complexity when challenges (complex anatomy, imaging quality, sur-
rounding structures, procedural challenges) are accumulating. AV, atrioventricular; RCA, right coronary artery. Adapted from Hahn et al.27 under
Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International (CC BY-NC-ND 4.0 DEED) license.
Other parameters have been recently proposed, including prognosis of patients undergoing isolated TV surgery. Indeed,
RVepulmonary artery (PA) coupling, which can be described recent data (2007-2017) from a single U.S. tertiary centre
as the relationship between RV contractility and RV afterload. (n ¼ 95; 41% reoperations) showed a low in-hospital mor-
RV contractility is a load-independent parameter64 that is best tality rate of 3.2%.68 The prognostic value of timely TV
assessed by means of pressure-volume loopederived end- surgery, particularly before the development of significant RV
systolic elastance (Ees), and RV-PA coupling is assessed as a dysfunction, was demonstrated in a recent large retrospective
ratio of end-systolic to arterial elastances (Ees/Ea).65 Nonin- study (n ¼ 534; mean age 70.8 years, 49% male, 44% with
vasive surrogates simplifying work-up include the tricuspid history of previous cardiac surgery).33 At a mean follow-up
annular plane systolic excursion (TAPSE)/pulmonary artery time of 38 months, patients who underwent TV surgery
systolic pressure (PASP) ratio, which may help to determine had better survival than those under medical treatment (62%
whether RV function adequately responds to the existing vs 35%; P < 0.001).
afterload conditions.65 Recent studies showed that patients Isolated tricuspid valve surgery (with or without previous
with a low TAPSE/PASP ratio (eg, 0.31 or 0.34) had a left-side surgery) has a IIa indication in the latest European
worse prognosis than those with a higher ratio in various guidelines in the absence of severe RV or LV dysfunction or
clinical situations, including after transcatheter TR treat- severe pulmonary vascular disease/hypertension (Table 2;
ment.65,66 Nonetheless, the initial testing of this concept was Fig. 3). TV repair should be performed whenever possible for
conducted on patient groups without significant TR. In sit- the treatment of TV disease requiring surgery.62,63 The
uations where severe TR is present, the conventional 2- benefit of TV repair over replacement was confirmed in a
chamber system, comprising the RV and PA, transforms recent propensity scoreematched analysis (175 pairs) showing
into a 3-compartment system encompassing the RV, PA, and lower 30-day (4.0% vs 8.0%; P ¼ 0.115) and late mortality
right atrium. The existence of a low-pressure outlet in the (cumulative survival rates at 3, 5, and 7 years: 84%, 75%, and
right atrium complicates the assessment of RV-PA coupling 56% vs 71%, 66%, and 58%, respectively; P ¼ 0.001)
considerably. Furthermore, the impact of TR treatment on without difference regarding reoperation, particularly when
this 3-compartment system has been addressed in only a single performed on a beating heart.69 Compared with suture
publication.66 RV free wall longitudinal strain has emerged as annuloplasty (such as the de Vega annuloplasty), the im-
a complementary sensitive parameter for the evaluation of RV plantation of a ring offers better long-term survival and
function, with the capability to detect subclinical damages freedom from recurrent TR with a trend toward fewer reop-
that may have been missed with conventional methods.67 erations.70 In experienced centres, most of the surgical in-
terventions are performed nowadays from a minimally
invasive right thoracic access.71
Isolated TV Surgery TV replacement is required in specific situations when
Early TR detection careful patient selection, modern sur- repair or previous replacement failed or when repair is not
gical techniques, and perioperative care have improved the feasible, such as in primary TR depending on the extent and
Volume 40 2024
Table 2. American and European Guidelines on the surgical and transcatheter management of tricuspid regurgitation (TR)62,63
Level of evidence and class of recommendation
Patient population AHA/ACC (2020) ESC/EACTS (2021) Comments
Primary TR
Severe primary TR undergoing left-side valve surgery I-B I-C
Symptomatic severe isolated primary TR without severe IIa-B I-C
RV dysfunction
Moderate (progressive) primary TR undergoing left-side IIa-B IIa-C AHA/ACC limits recommendation to
valve surgery patient with previous signs and
symptoms of right-side HF
Asymptomatic severe isolated TR and progressive RV IIb-C IIa-C ESC/EACTS guidelines make no mention
dilation or dysfunction of right-sided dysfunction.
Same recommendation for mildly
symptomatic TR according to ESC/
EACTS guidelines
Secondary TR
Severe secondary TR undergoing left-side valve surgery I-B I-B
Mild or moderate (progressive) secondary TR with IIa-B IIa-B ESC/EACTS guidelines do not consider
dilated annulus ( 40 mm or > 21 mm/m2) “progressive” disease as a criteria because
undergoing left-side valve surgery the presence of RV dilation seems
sufficient to indicate repair in patients
undergoing left-side surgery
Mild or moderate (progressive) secondary TR IIa-B e
undergoing left-side valve surgery even in the
absence of annular dilation when previous right-
side HF has been documented
Severe secondary TR (with or without previous left-side e IIa-B
surgery), symptomatic or with RV dilation, in the
absence of severe RV or LV dysfunction and
severe pulmonary vascular disease/hypertension
Symptomatic severe isolated secondary TR attributable IIa-B e
to annular dilation (in the absence of PHT or
left-side disease), poorly responsive to medical
therapy
Symptomatic severe secondary TR after previous IIb-B e
left-side surgery in the absence of recurrent left-
side valve dysfunction; surgery may be considered
in the absence of severe RV dysfunction or severe
pulmonary hypertension
Transcatheter treatment of symptomatic secondary e IIb-C
severe TR may be considered in inoperable
patients at a heart valve centre with expertise in
the treatment of tricuspid valve disease.
CIED-related TR
No recommendation No recommendation
ACC, American College of Cardiology’ AHA, American Heart Association; CIED, cardiac implantable electronic device; EACTS, European Association for
Cardio-Thoracic Surgery; ESC, European Society of Cardiology; HF, heart failure; PHT, pulmonary hypertension; RV, right ventricular.
severity of the underlying pathology or in secondary TR when Current guidelines recommend concomitant TV repair in
the TV leaflets are tethered or the annulus severely dilated.72 patients with a dilated annulus ( 40 mm or > 21 mm/m2)
Patients with a pacemaker lead crossing the TV may also undergoing left-side valve surgery, independently from TR
require valve replacement, particularly when TR is caused by grade (Table 2; Fig. 4).62,63 Concomitant annuloplasty for
the lead. A tethering height > 0.5 cm and a tethering area > secondary TR results in excellent safety and survival, with
0.8 cm2 are predictive of recurrent TR early and 1 year after freedom from moderate or worse residual/recurrent TR in 89
TV annuloplasty.73 TV replacement has been associated with 8% at 3-year follow-up.77 Furthermore, recent data from a
improved survival compared with TV repair in the subgroup randomised controlled trial suggest that TR repair is associated
of patients with tricuspid annular diameter > 44 mm.74 with a lower incidence of the combined endpoint of death,
reoperation for TR, progression of TR by 2 grades from
baseline, or presence of severe TR at 2 years than mitral valve
Concomitant TV Surgery in Patients Undergoing surgery alone.78 Although the trial was not powered to analyse
Left-Side Heart Surgery the primary endpoint according to the severity of TR at
According to analyses of the Society of Thoracic Surgeons baseline, a post hoc analysis showed that TR progression
National Database (2000-2010, 54,375 patients), the vast occurred almost exclusively in patients with moderate TR at
majority of TV surgeries were repairs (89%) and performed baseline. This observation calls into question the recommen-
during left-side procedures (86%).50 Several studies have dation to perform preventive annuloplasty in patients with a
challenged the notion that secondary TR may resolve once dilated tricuspid annulus and less than moderate TR.
successful mitral valve surgery has been performed.75,76 Importantly, there was a higher permanent pacemaker
Samim et al. 191
Figure 3. Algorithm for tricuspid valve (TV) treatment in patients without concomitant left-side valve disease.11,62 CIED, cardiac implantable
electronic device; LV, left ventricle; PHT, pulmonary hypertension; RV, right ventricle, TR, tricuspid regurgitation.
implantation rate in the intervention group (14.1% vs 2.5%, Surgery European valvular heart disease guidelines (Table 2),
rate ratio 5.75, 95% confidence interval [CI] 2.27-14.60).78 based on a propensity scoreematched cohort study (213
Observational studies have reported lower permanent pace- pairs) suggesting that the prognosis of patients with severe TR
maker implantation rates after TV repair of 2.4% to is improved after transcatheter compared with conservative
15%.79-81 Interestingly, in a recent nationwide study per- treatment.31
formed from 2006 to 2020 in Sweden (n ¼ 1502), a similar Tricuspid transcatheter edge-to-edge repair (T-TEER) is
30-day permanent pacemaker implantation rate (14.2%) was the most frequently used technique84-86 and the first-line
observed.82 Independent risk factors were concomitant mitral option in patients with primary TR due to flail/prolapse
valve surgery (odds ratio 2.07, 95% CI 1.34-3.27), ablation and in patients with secondary TR with a coaptation gap
surgery (odds ratio 1.59, 95% CI 1.12-2.23), and surgery < 8.5 mm, an anteroseptal jet location, and mild or moderate
performed in a low-volume centre (odds ratio 1.85, 95% CI tethering (Fig. 5).11 In addition to a growing corpus of
1.17-2.83).82 However, permanent pacemaker implantation observational data supporting the procedure, the recently
did not increase long-term mortality or the cumulative inci- published Trial to Evaluate Cardiovascular Outcomes in
dence of HF and major adverse cardiovascular events, but was Patients Treated With the Tricuspid Valve Repair System
associated with several short- and long-term complications (TRILUMINATE) trial was the first randomised prospective
such as thrombosis, infection, pacemaker-induced TR, and multicentre study to compare interventional TR management
pacing-induced ventricular dysfunction.83 and medical treatment. The primary endpoint was a hierarchic
composite that included death from any cause or TV surgery,
HF hospitalisation, and an improvement in quality of life as
Transcatheter Interventions for TR measured with the Kansas City Cardiomyopathy Question-
Tricuspid transcatheter interventions emerge as attractive naire (KCCQ), with an improvement defined as 15 points
alternatives to open-heart surgery. A IIb recommendation for increase in the KCCQ score at 1 year. Superiority was met for
transcatheter therapies in inoperable patients with secondary T-TEER (win ratio 1.48, 95% CI 1.06-2.13; P ¼ 0.02) but
TR was first introduced in the 2021 European Society of was driven by quality-of-life improvement only. While no
Cardiology/European Association for Cardio-Thoracic significant differences were found regarding 6-minute walking
Volume 40 2024
Figure 4. Algorithm for tricuspid valve (TV) treatment in patients with concomitant left-side valve disease.11,62 CIED, cardiac implantable electronic
device; TA, tricuspid annulus; TR, tricuspid regurgitation.
distance (6MWD) in the initial cohort, statistical significance Regurgitation Repair With Cardioband Transcatheter System
was reached (paired difference 27m; P ¼ 0.01) in the recently (TRI-REPAIR) study, the septolateral annular diameter was
presented extended cohort (n ¼ 572). Although a placebo reduced by 16% (P ¼ 0.006, paired analysis compared with
effect cannot be completely ruled out, almost twice as many baseline) and 72% of the patients (P ¼ 0.016, paired analysis
patients in the T-TEER group had a KCCQ improvement of compared with baseline) had moderate or less TR grade and
15 points, and its magnitude closely related to TR reduc- more than 80% of the patients remained in New York Heart
tion. In addition, the procedure was extremely safe, and the Association (NYHA) functional class I/II at 2-year follow-
result sustained at 1 year.87 Compared with real-world regis- up.88 Importantly, the efficacy and safety of the procedure
tries (PASCAL for Tricuspid RegurgitationdA European were not affected by leaflet morphology, including complex
Registry [PASTE], An Observational Real-world Study Eval- anatomies with > 3 leaflets.89 Limitations include procedure
uating Severe Tricuspid Regurgitation Patients Treated With complexity and duration, the risk of damaging the right cor-
the Abbott TriClip Device [bRIGHT], Edwards EVOQUE onary artery, and poor effect in patients with large anatomy
Tricuspid Valve Replacement: Investigation of Safety and and severe leaflet tethering. In patients with advanced TR, a
Clinical Efficacy after Replacement of Tricuspid Valve with staged approach including annuloplasty with subsequent T-
Transcatheter Device [TRISCEND I]), the participants in the TEER may represent a viable option in well informed can-
TRILUMINATE trial had fewer HF events and symptoms didates accepting the prospect of 2 separate procedures
before inclusion, a smaller coaptation gap, and a lower pace- (Fig. 5).90
maker rate and may therefore represent a less advanced and
complex population in whom early mortality reduction is
rather unlikely to be observed. Several other randomised trials Table 3. Proposed echocardiographic cutoffs for right ventricular
are ongoing in different countries and may provide further function according to the TVARC
information on the best candidates, as well as the most Mild Moderate Severe
appropriate timing of intervention. dysfunction dysfunction dysfunction
In analogy to surgical repair, transcatheter annuloplasty TAPSE, mm 14-17 10-13 < 10
may be particularly advantageous for patients with predomi- RV TDI S0 , cm/s 9-11 6-8 <6
nant annular dilation (particularly, atrial secondary TR) with RV GLS, % 18-21 14-17 < 14
RV FWS, % 20-23 15-19 < 15
central jet location and without extensive coaptation gap, FAC, % 34-37 30-33 < 30
pseudoprolapse, or severe leaflet tethering (Fig. 5),11 Trans- RVEF (3DE), % 45-50 35-45 < 35
catheter annuloplasty mimics surgical repair techniques and 3DE, 3-dimensional echocardiography; FAC, fractional area change;
counteracts one of the main mechanisms of secondary TR by FWS, free wall strain; GLS, global longitudinal strain; RV, right ventricular;
directly reducing the annular dimensions. The Cardioband RVEF, right ventricular ejection fraction; TAPSE, tricuspid annular plane
tricuspid direct annuloplasty system is the only one approved systolic excursion; TDI S0 , tissue Doppler imaging tricuspid annular velocity;
in Europe. In the multicentre prospective Tricuspid TVARC, Tricuspid Valve Academic Research Consortium.
Samim et al. 193
Figure 5. Algorithm for transcatheter tricuspid valve (TV) treatment in patients at increased surgical risk.11,62 CIED, cardiac implantable electronic
device; TR, tricuspid regurgitation; T-TEER, tricuspid transcatheter edge-to-edge repair; TTVR, transcatheter tricuspid valve replacement.
For patients with an anatomy unsuitable for repair, trans- Dedicated bicaval systems (Tricento, TricValve, and Tri-
catheter tricuspid valve replacement (TTVR) emerges as the lium) are emerging and the early clinical experience shows
most appropriate option (Fig. 5).11 The 1-year results of the promising results with signs of RV reverse remodelling and
single-arm, prospective, global, multicentre TRISCEND improvement in both quality of life metrics and NYHA
study of the Evoque TTVR system showed excellent efficacy functional class up to 6-month follow-up.92,93
and quality of life improvement in symptomatic patients with
at least moderate secondary or primary TR. At 1 year, 90.1%
survival and 88.4% freedom from HF hospitalisation were Combined Transcatheter Treatment of Mitral
reported, and 97.6% of patients had mild or trace TR and and Tricuspid Regurgitation
93% were in NYHA functional class I or II with significant The concept that TR does not resolve after successful
improvement in quality of life.91 Adverse events consisted of treatment of mitral valve disease remains true for high-risk
permanent pacemaker implantation in 13% of the patients patients undergoing transcatheter treatment. In patients
within 30 days and the occurrence of severe bleedings in about undergoing mitral transcatheter edge-to-edge repair (M-
one-fourth due to intensive antithrombotic treatment after the TEER), a retrospective study suggested that the degree of
procedure. The six-month results of the randomised TR remained unchanged or worsened in almost 80% of
TRISCEND II study confirmed a promising effect on patients at 1-year follow-up after M-TEER.94 Another study
quality of life metrics (D KCCQ 17.8 points, D 6MWD reported that moderate TR before M-TEER remained un-
30.9 m) that could potentially translate into a reduction of changed in 70% of the patients 2 years after follow-up.95 In
hard clinical endpoints during longer-term follow-up. patients with combined mitral regurgitation and TR at
Table 4 summarises the advantages and disadvantages of increased surgical risk, recent hypothesis-generating data
transcatheter TV repair and replacement, as well as potential suggest that combined M- and T-TEER may be associated
criteria favouring replacement. Particular care is required with improved 1-year survival compared with isolated M-
when considering lead jailing during TTVR, because lead TEER.96 Data from the Transcatheter TriValve and
dysfunction can infrequently occur. Systematic device inter- Transcatheter Mitral Valve Interventions (TRAMI) registries
rogation before the intervention to evaluate the consequence indicate that combined M- and T-TEER provides superior
of a potential lead malfunction and involvement of electro- hemodynamic and functional outcomes (NYHA functional
physiologists are of paramount importance. class, N-terminal proeB-type natriuretic peptide levels, and
Heterotopic caval valve implantation may be considered 6MWD) compared with isolated M-TEER and is associated
as a palliative option after exclusion of the feasibility of with reduced rates of HF hospitalisations during up to 18
repairing or replacing the TV. It aims to mitigate symp- months of follow-up.84
toms related to TR and associated RV failure, reduce Concomitant transcatheter treatment of TR during non-
venous congestion, and limit renal and hepatic damage. tricuspid interventions aims to replicate the surgical approach.
Volume 40 2024
Table 4. Advantages and disadvantages of transcatheter tricuspid valve repair and replacement (with anatomic criteria favouring replacement)11
Repair Replacement Criteria favouring replacement
High procedural safety Higher risk of complications Large coaptation gap and
Minimal interaction with the native Risk of new pacemaker implantation; predominantly central gap;
anatomy Interaction with the subvalvular Severe leaflet tethering;
apparatus or RV lead Incidental or interacting CIED RV
Low thrombogenicity Risk of valve thrombosis lead;
Reduction of regurgitation highly Highly effective in reducing Complex leaflet morphology (> 3);
dependent on anatomy and image regurgitation; Leaflet thickening/perforation
quality: not always predictable Risk of hemolysis associated with PVL shortening (rheumatic, carcinoid,
Higher risk of recurrent TR during Durability likely (though unknown) postendocarditis);
long-term FU Previous surgical repair or
bioprosthetic valve replacement
CIED, cardiac implantable electronic device; FU, follow-up; PVL, paravalvular leak; RV, right ventricular.
However, the advantage of transcatheter treatment is the allow reverse remodelling of the RV, patients should
possibility to stage the procedures and therefore follow the maintain the preprocedural diuretic regimen for at least 3
evolution of TR after successful correction of left-side disease. months after the intervention. A few patients may require
The timing of each intervention can therefore be optimised to careful down-titration of diuretics if they experience early
avoid unnecessary procedures, and the approach can be postprocedural polyuria (usually within 24-48 hours) due to
adapted to disease etiology (eg, atrial vs ventricular secondary increased renal arteriovenous pressure gradient.
TR, the presence and type of PHT, and the presence or To prevent infective endocarditis, all patients with cor-
absence of RV-PA uncoupling).97 Prospective data are needed rected TR should receive lifelong antibiotic prophylaxis owing
to evaluate different strategies and the most appropriate to the increased risk of bacteremia in the venous circulation.
timing of the second valve procedure. Postprocedural outpatient follow-ups are usually recom-
mended at 1, 6, and 12 months, followed by annual visits.
These assessments should include monitoring of N-terminal
Postinterventional Care and Follow-up proeB-type natriuretic peptide and renal and liver function,
Because most TR patients (w 70%) suffer from AF,30,33 transthoracic echocardiography, and NYHA functional class
oral anticoagulation with vitamin K antagonist or direct oral and quality of life assessment.
anticoagulant are indicated in the vast majority of patients.
For those in sinus rhythm after surgical or transcatheter TV
repair, single antiplatelet therapy with aspirin for up to 6 Future Perspectives and Challenges: The
months should be considered.98 After valve replacement, a Essential Role of Imaging
strict antithrombotic regimen should be observed, because the Several unknowns remain concerning the impact of sur-
thrombotic risk is higher in the low-pressure right heart sys- gical or transcatheter TR treatment on hard clinical endpoints,
tem, particularly in the early postinterventional phase, and especially hospitalisation for HF and mortality (Fig. 6). In
hypoattenuated leaflet thickening has been described after addition, the exact timing of intervention in relation to the
TTVR.99 However, current evidence does not support any occurrence of progressive cardiac damage, as well as clinical
specific antithrombotic regimens. Direct oral anticoagulant disease progression with renal and liver impairment, has to be
and vitamin K antagonist, preferably long-term, have both defined. In patients undergoing TTVR, the appropriate
been used in ongoing studies investigating transcatheter antithrombotic regimen balancing the risk of bleeding with
replacement systems.98 Combination with aspirin has been those of thrombotic leaflet thickening and valve thrombosis
suggested in selected cases, particularly after the detection of also require further investigations.
hypoattenuated leaflet thickening, but certainly carries a Imaging for diagnosis and procedural guiding remains one
higher bleeding risk. of the most important limitations of transcatheter TV in-
In patients with HF with reduced ejection fraction, HF terventions. Parameters for accurate and reproducible assess-
therapy should be maintained according to guidelines100 and ment of the RV in patients with severe TR (ideally, preload
may even be up-titrated after improvement in renal function independent) still need to be defined and prospectively
as a result of improved cardiac output, reduced venous investigated.
congestion and better renal perfusion. In patients with HF While TEE remains the standard for transcatheter TV
with mildly reduced or preserved ejection fraction,101,102 procedures, 3D intracardiac echocardiography (ICE) plays an
sodium-glucose cotransporter 2 inhibitor treatment should emerging role, either as an adjunctive or a standalone tool in
be maintained owing to its diuretic, nephroprotective, and patients with contraindications to TEE or insufficient imaging
symptomatic effects.103,104 In case of residual TR, to quality.105,106 Theoretically, ICE does not require general
counterbalance the activation of the renin-angiotensin- anaesthesia, which is particularly attractive for elderly or pol-
aldosterone system associated with hepatic congestion, an ymorbid patients.105,107 The latest ICE catheters (Table 5)
aldosterone antagonist may be considered with regular provide 3D views with the possibility to image the cardiac
monitoring of renal function and electrolytes. Finally, to structures in 2 or several planes simultaneously using either
Samim et al. 195
Figure 6. Future prospects and challenges of tricuspid valve interventions. RV, right ventricle; TR, tricuspid regurgitation.
X-plane (Philipps) or multiplanar reconstruction, which is resolution inferior to TEE, particularly in patients with a
essential for all techniques relying on leaflet grasping for severely enlarged right atrium. The addition of a steerable
anchoring (Fig. 7). Current downsides include limited reso- sheath is able to improve imaging stability, but further in-
lution of 3D images, interactions with the delivery catheter creases costs. Because the catheter is introduced via the
impairing stability and generating artifacts, and an imaging femoral venous access, French size is of less relevance.
Table 5. Currently available intracardiac echocardiography catheters and their characteristics

BioSense Webster Siemens Philips
Compatible console GE Siemens Philips EPIQ
Product name NuVision AcuNav Volume VeriSight Pro
Catheter size 10 F 12.5 F 9F
Transducer element Array/840 Twisted linear/128 xMatrix/840
Sector size 90 90 90 50 90 90
Working length 90 cm 90 cm 90 cm
2D and 3D imaging Yes Yes Yes
3D colour imaging Yes Yes Yes
Live X-plane imaging Yes Yes Yes
MultiVue/MultiPlanar reconstruction Yes Yes Yes
Volume 40 2024
Figure 7. Imaging innovations for the guiding of transcatheter tricuspid valve procedures. (A) Fluoroscopy view of the intracardiac echocardiography
(ICE) catheter position relative to the tricuspid transcatheter edge-to-edge repair (T-TEER) delivery catheter in the right atrium. (B) Multiplanar
reconstruction provided by the newest Siemens LUMOS 4D ICE system during mainly ICE-guided T-TEER in a patient with low-quality trans-
esophageal echocardiography (TEE) imaging. (C) Fusion imaging between fluoroscopy and TEE (latest version of the Philipps EchoNavigator) during
transcatheter tricuspid valve replacement with the Edwards EVOQUE system. (D) Simultaneous multiplanar reconstruction allowing controlled valve
deployment in all 3 dimensions.
Fusion imaging between TEE and fluoroscopy represents quality of life improvement depending on the magnitude of
another innovative imaging technique improving orientation TR correction has been confirmed by 2 recent randomised
in the right heart chambers (Fig. 7). Although a detailed trials. Further research is needed to understand which patients
visualisation of the anatomy is not possible, the superimposed of this extremely heterogeneous population benefit the most
model based on automatic structure recognition using the from an intervention performed at an expert centre.
echocardiographic images contributes to optimising catheter
trajectory and device orientation.
Ethics Statement
Conclusion The article has been written in agreement with the Hel-
Intensive research activities around the TV and the right sinki declaration and in accordance with the applicable Swiss
sheart during recent years have dramatically changed the legislation.
perception of TR as a clinical entity and an important
contributor to the burden of HF. Technologic evolution of
imaging and interventions and improved surgical outcomes in
well selected patients offer novel treatment opportunities. Patient Consent
Although the impacts of TR treatment on hard endpoints still The authors confirm that patient consent is not applicable
need to be demonstrated regardless of the technique, relevant to this article, as it is a review article.
Samim et al. 197
Funding Sources 16. Arsalan M, Walther T, Smith RL 2nd, Grayburn PA. Tricuspid
The authors have no funding sources to declare. regurgitation diagnosis and treatment. Eur Heart J 2017;38:634-8.
17. Badano LP, Muraru D, Enriquez-Sarano M. Assessment of functional

tricuspid regurgitation. Eur Heart J 2013;34:1875-85.
Disclosures
Dr Samim received funding for an online course from 18. Lee RC, Friedman SE, Kono AT, Greenberg ML, Palac RT. Tricuspid
Edwards Lifesciences. Dr Praz was compensated for travel regurgitation following implantation of endocardial leads: incidence and
expenses by Abbott Vascular, Edwards Lifesciences, Polares predictors. Pacing Clin Electrophysiol 2015;38:1267-74.
Medical, Medira, and Siemens Healthineers. The other au-
thors have no conflicts of interest to disclose. 19. Baquero GA, Yadav P, Skibba JB, et al. Clinical significance of increased
tricuspid valve incompetence following implantation of ventricular
leads. J Interv Card Electrophysiol 2013;38:197-202.
References
20. Kim JB, Spevack DM, Tunick PA, et al. The effect of transvenous
1. Asmarats L, Taramasso M, Rodes-Cabau J. Tricuspid valve disease: pacemaker and implantable cardioverter defibrillator lead placement on
diagnosis, prognosis and management of a rapidly evolving field. Nat tricuspid valve function: an observational study. J Am Soc Echocardiogr
Rev Cardiol 2019;16:538-54. 2008;21:284-7.
2. Nkomo VT, Gardin JM, Skelton TN, et al. Burden of valvular heart 21. Beurskens NEG, Tjong FVY, de Bruin-Bon RHA, et al. Impact of
diseases: a population-based study. Lancet 2006;3689540:1005-11. leadless pacemaker therapy on cardiac and atrioventricular valve func-
3. Topilsky Y, Maltais S, Medina Inojosa J, et al. Burden of tricuspid tion through 12 months of follow-up. Circ Arrhythm Electrophysiol
regurgitation in patients diagnosed in the community setting. JACC 2019;12:e007124.
Cardiovasc Imaging 2019;12:433-42.
22. Hai JJ, Mao Y, Zhen Z, et al. Close proximity of leadless pacemaker to
4. Cahill TJ, Prothero A, Wilson J, et al. Community prevalence, mech- tricuspid annulus predicts worse tricuspid regurgitation following septal
anisms and outcome of mitral or tricuspid regurgitation. Heart 2021. implantation. Circ Arrhythm Electrophysiol 2021;14:e009530.
5. Singh JP, Evans JC, Levy D, et al. Prevalence and clinical determinants 23. Addetia K, Harb SC, Hahn RT, Kapadia S, Lang RM. Cardiac
of mitral, tricuspid, and aortic regurgitation (the Framingham Heart implantable electronic device lead-induced tricuspid regurgitation.
Study). Am J Cardiol 1999;83:897-902. JACC Cardiovasc Imaging 2019;12:622-36.
6. Offen S, Playford D, Strange G, Stewart S, Celermajer DS. Adverse 24. Ehieli WL, Boll DT, Marin D, et al. Use of preprocedural MDCT for
prognostic impact of even mild or moderate tricuspid regurgitation: cardiac implantable electric device lead extraction: frequency of findings
insights from the National Echocardiography Database of Australia. that change management. AJR Am J Roentgenol 2017;208:770-6.
J Am Soc Echocardiogr 2022;35:810-7.
25. Gmeiner J, Sadoni S, Orban M, et al. Prevention of pacemaker lead-
7. Mutlak D, Khalil J, Lessick J, et al. Risk factors for the development of induced tricuspid regurgitation by transesophageal echocardiography
functional tricuspid regurgitation and their population-attributable guided implantation. JACC Cardiovasc Interv 2021;14:2636-8.
fractions. JACC Cardiovasc Imaging 2020;13:1643-51.
26. Holda MK, Zhingre Sanchez JD, Bateman MG, Iaizzo PA. Right
8. Prihadi EA, van der Bijl P, Gursoy E, et al. Development of significant atrioventricular valve leaflet morphology redefined: implications for
tricuspid regurgitation over time and prognostic implications: new in- transcatheter repair procedures. JACC Cardiovasc Interv 2019;12:
sights into natural history. Eur Heart J 2018;39:3574-81. 169-78.
9. Beale AL, Nanayakkara S, Segan L, et al. Sex differences in heart failure 27. Hahn RT, Weckbach LT, Noack T, et al. Proposal for a standard
with preserved ejection fraction pathophysiology: a detailed invasive echocardiographic tricuspid valve nomenclature. JACC Cardiovasc
hemodynamic and echocardiographic analysis. JACC Heart Fail 2019;7: Imaging 2021;14:1299-305.
239-49.
28. Russo G, Taramasso M, Pedicino D, et al. Challenges and future per-
10. Kwak JJ, Kim YJ, Kim MK, et al. Development of tricuspid regurgi-
spectives of transcatheter tricuspid valve interventions: adopt old stra-
tation late after left-sided valve surgery: a single-center experience with
tegies or adapt to new opportunities? Eur J Heart Fail 2022;24:442-54.
long-term echocardiographic examinations. Am Heart J 2008;155:
732-7. 29. Asmarats L, Puri R, Latib A, Navia JL, Rodes-Cabau J. Transcatheter
tricuspid valve interventions: landscape, challenges, and future di-
11. Praz F, Muraru D, Kreidel F, et al. Transcatheter treatment for tricuspid
rections. J Am Coll Cardiol 2018;71:2935-56.
valve disease. EuroIntervention 2021;17:791-808.
12. Lancellotti P, Pibarot P, Chambers J, et al. Multi-modality imaging 30. Samim D, Praz F, Cochard B, et al. Natural history and mid-term
assessment of native valvular regurgitation: an EACVI and ESC council prognosis of severe tricuspid regurgitation: a cohort study. Front Car-
of valvular heart disease position paper. Eur Heart J Cardiovasc Imaging diovasc Med 2022;9:1026230.
2022;23:e171-232.
31. Taramasso M, Benfari G, van der Bijl P, et al. Transcatheter versus
13. Hahn RT. Tricuspid regurgitation. N Engl J Med 2023;388:1876-91. medical treatment of patients with symptomatic severe tricuspid
regurgitation. J Am Coll Cardiol 2019;74:2998-3008.
14. Prihadi EA, Delgado V, Leon MB, et al. Morphologic types of tricuspid
regurgitation: characteristics and prognostic implications. JACC Car- 32. Topilsky Y, Nkomo VT, Vatury O, et al. Clinical outcome of isolated
diovasc Imaging 2019;12:491-9. tricuspid regurgitation. JACC Cardiovasc Imaging 2014;7:1185-94.
15. Hahn RT, Lawlor MK, Davidson CJ, et al. Tricuspid Valve Academic 33. Kadri AN, Menon V, Sammour YM, et al. Outcomes of patients with
Research Consortium definitions for tricuspid regurgitation and trial severe tricuspid regurgitation and congestive heart failure. Heart
end points. J Am Coll Cardiol 2023;82:1711-35. 2019;105:1813-7.
Volume 40 2024
34. Leon MB, Smith CR, Mack M, et al. Transcatheter aortic-valve im- 51. Axtell AL, Bhambhani V, Moonsamy P, et al. Surgery does not improve
plantation for aortic stenosis in patients who cannot undergo surgery. survival in patients with isolated severe tricuspid regurgitation. J Am
N Engl J Med 2010;363:1597-607. Coll Cardiol 2019;74:715-25.
35. Rao VN, Giczewska A, Chiswell K, et al. Long-term outcomes of 52. Staab ME, Nishimura RA, Dearani JA. Isolated tricuspid valve surgery
phenoclusters in severe tricuspid regurgitation. Eur Heart J 2023;44: for severe tricuspid regurgitation following prior left heart valve surgery:
1910-23. analysis of outcome in 34 patients. J Heart Valve Dis 1999;8:567-74.
36. Gavazzoni M, Heilbron F, Badano LP, et al. The atrial secondary 53. Zack CJ, Fender EA, Chandrashekar P, et al. National trends and
tricuspid regurgitation is associated to more favorable outcome than the outcomes in isolated tricuspid valve surgery. J Am Coll Cardiol
ventricular phenotype. Front Cardiovasc Med 2022;9:1022755. 2017;70:2953-60.
37. Galloo X, Dietz MF, Fortuni F, et al. Prognostic implications of atrial vs 54. Wang TKM, Akyuz K, Xu B, et al. Early surgery is associated with
ventricular functional tricuspid regurgitation. Eur Heart J Cardiovasc improved long-term survival compared to class I indication for isolated
Imaging 2023;24:733-41. severe tricuspid regurgitation. J Thorac Cardiovasc Surg 2023;166:
91-100.
38. Itelman E, Vatury O, Kuperstein R, et al. The association of severe
tricuspid regurgitation with poor survival is modified by right ventricular 55. Dreyfus J, Audureau E, Bohbot Y, et al. TRI-SCORE: a new risk score
pressure and function: insights from SHEBAHEART Big Data. J Am for in-hospital mortality prediction after isolated tricuspid valve surgery.
Soc Echocardiogr 2022;35:1028-36. Eur Heart J 2022;43:654-62.
39. Peri Y, Sadeh B, Sherez C, et al. Quantitative assessment of effective 56. Dreyfus J, Bohbot Y, Coisne A, et al. Predictive value of the TRI-
regurgitant orifice: impact on risk stratification, and cutoff for severe and SCORE for in-hospital mortality after redo isolated tricuspid valve
torrential tricuspid regurgitation grade. Eur Heart J Cardiovasc Imaging surgery. Heart 2023;109:951-8.
2020;21:768-76.
57. Dreyfus J, Galloo X, Taramasso M, et al. TRI-SCORE and benefit of
40. Hahn RT, Zamorano JL. The need for a new tricuspid regurgitation intervention in patients with severe tricuspid regurgitation [e-pub ahead
grading scheme. Eur Heart J Cardiovasc Imaging 2017;18:1342-3. of print]. Eur Heart J. doi:10.1093/eurheartj/ehad585
58. Ailawadi G, Lapar DJ, Swenson BR, et al. Model for end-stage liver
41. Go YY, Dulgheru R, Lancellotti P. The conundrum of tricuspid
disease predicts mortality for tricuspid valve surgery. Ann Thorac Surg
regurgitation grading. Front Cardiovasc Med 2018;5:164.
2009;87:1460-7 [discussion 1467-8].
42. Santoro C, Marco del Castillo A, Gonzalez-Gomez A, et al. Mid-term
59. Färber G, Marx J, Scherag A, et al. Risk stratification for isolated
outcome of severe tricuspid regurgitation: are there any differences ac-
tricuspid valve surgery assisted using the Model for End-Stage Liver
cording to mechanism and severity? Eur Heart J Cardiovasc Imaging
Disease score. J Thorac Cardiovasc Surg 2023;166:1433-14341.e1.
2019;20:1035-42.
60. Dietz MF, Prihadi EA, van der Bijl P, et al. Prognostic implications of
43. Omori T, Uno G, Shimada S, et al. Impact of new grading system and
staging right heart failure in patients with significant secondary tricuspid
new hemodynamic classification on long-term outcome in patients with
regurgitation. JACC Heart Fail 2020;8:627-36.
severe tricuspid regurgitation. Circ Cardiovasc Imaging 2021;14:
e011805. 61. Galloo X, Stassen J, Butcher SC, et al. Staging right heart failure in
patients with tricuspid regurgitation undergoing tricuspid surgery. Eur J
44. Hahn RT, Badano LP, Bartko PE, et al. Tricuspid regurgitation: recent Cardiothorac Surg 2022;62:2.
advances in understanding pathophysiology, severity grading and
outcome. Eur Heart J Cardiovasc Imaging 2022;23:913-29. 62. Vahanian A, Beyersdorf F, Praz F, et al. 2021 ESC/EACTS guidelines
for the management of valvular heart disease. Eur Heart J 2022;43:
45. Zhan Y, Debs D, Khan MA, et al. Natural history of functional 561-632.
tricuspid regurgitation quantified by cardiovascular magnetic resonance.
J Am Coll Cardiol 2020;76:1291-301. 63. Otto CM, Nishimura RA, Bonow RO, et al. 2020 ACC/AHA guideline
for the management of patients with valvular heart disease: executive
46. Hahn RT, Thomas JD, Khalique OK, et al. Imaging assessment of summary: a report of the American College of Cardiology/American
tricuspid regurgitation severity. JACC Cardiovasc Imaging 2019;12: Heart Association Joint Committee on Clinical Practice Guidelines.
469-90. Circulation 2021;143:e35-71.
47. Hell MM, Emrich T, Kreidel F, et al. Computed tomography imaging 64. Todaro MC, Carerj S, Zito C, et al. Echocardiographic evaluation of
needs for novel transcatheter tricuspid valve repair and replacement right ventricularearterial coupling in pulmonary hypertension. Am J
therapies. Eur Heart J Cardiovasc Imaging 2021;22:601-10. Cardiovasc Dis 2020;10:272-83.
48. Dreyfus J, Ghalem N, Garbarz E, et al. Timing of referral of patients 65. Tello K, Wan J, Dalmer A, et al. Validation of the tricuspid annular
with severe isolated tricuspid valve regurgitation to surgeons (from a plane systolic excursion/systolic pulmonary artery pressure ratio for the
French nationwide database). Am J Cardiol 2018;122:323-6. assessment of right ventricularearterial coupling in severe pulmonary
hypertension. Circ Cardiovasc Imaging 2019;12:e009047.
49. Scotti A, Sturla M, Granada JF, et al. Outcomes of isolated tricuspid
valve replacement: a systematic review and meta-analysis of 5,316 pa- 66. Brener MI, Lurz P, Hausleiter J, et al. Right ventricularepulmonary
tients from 35 studies. EuroIntervention 2022;18:840-51. arterial coupling and afterload reserve in patients undergoing trans-
catheter tricuspid valve repair. J Am Coll Cardiol 2022;79:448-61.
50. Kilic A, Saha-Chaudhuri P, Rankin JS, Conte JV. Trends and outcomes
of tricuspid valve surgery in North America: an analysis of more than 67. Hinojar R, Zamorano JL, Gonzalez Gomez A, et al. Prognostic impact
50,000 patients from the Society of Thoracic Surgeons database. Ann of right ventricular strain in isolated severe tricuspid regurgitation. J Am
Thorac Surg 2013;96:1546-52 [discussion: 52]. Soc Echocardiogr 2023;36:615-23.
Samim et al. 199
68. Hamandi M, Smith RL, Ryan WH, et al. Outcomes of isolated 86. Lurz P, Stephan von Bardeleben R, Weber M, et al. Transcatheter edge-
tricuspid valve surgery have improved in the modern era. Ann Thorac to-edge repair for treatment of tricuspid regurgitation. J Am Coll Car-
Surg 2019;108:11-5. diol 2021;77:229-39.
69. Russo M, di Mauro M, Saitto G, et al. Outcome of patients undergoing 87. Sorajja P, Whisenant B, Hamid N, et al. Transcatheter repair for
isolated tricuspid repair or replacement surgery. Eur J Cardiothorac Surg patients with tricuspid regurgitation. N Engl J Med 2023;388:
2022;62:ezac230. 1833-42.
70. Tang GH, David TE, Singh SK, et al. Tricuspid valve repair with an 88. Nickenig G, Weber M, Schuler R, et al. Tricuspid valve repair
annuloplasty ring results in improved long-term outcomes. Circulation with the Cardioband system: two-year outcomes of the multicentre,
2006;114(1 suppl):I577-81. prospective TRI-REPAIR study. EuroIntervention 2021;16:
e1264-71.
71. Abdelbar A, Kenawy A, Zacharias J. Minimally invasive tricuspid valve
surgery. J Thorac Dis 2021;13:1982-92. 89. Korber MI, Roder F, Gercek M, et al. Leaflet morphology and its im-
plications for direct transcatheter annuloplasty of tricuspid regurgitation.
72. Dreyfus J, Dreyfus GD, Taramasso M. Tricuspid valve replacement: the JACC Cardiovasc Interv 2023;16:693-702.
old and the new. Prog Cardiovasc Dis 2022;72:102-13.
90. Ivannikova M, Rudolph TK, Friedrichs K, et al. A stepwise approach for
73. Fukuda S, Saracino G, Matsumura Y, et al. Three-dimensional geom- transcatheter edge-to-edge repair in very advanced tricuspid regurgita-
etry of the tricuspid annulus in healthy subjects and in patients with tion. JACC Case Rep 2023;16:101874.
functional tricuspid regurgitation: a real-time, 3-dimensional echocar-
diographic study. Circulation 2006;114(1 suppl):I492-8. 91. Edwards Lifesciences: Edwards announces one-year data on transfemoral
transcatheter tricuspid valve replacement. November 27, 2022. Avail-
74. Park SJ, Oh JK, Kim SO, et al. Determinants of clinical outcomes of
able at: https://www.edwards.com/newsroom/news/2022-11-27-
surgery for isolated severe tricuspid regurgitation. Heart 2021;107:
edwards-announces-one-year-data-on-transfemoral-tr. Accessed July
403-10.
29, 2023.
75. Matsunaga A, Duran CM. Progression of tricuspid regurgitation after
92. Wild MG, Lubos E, Cruz-Gonzalez I, et al. Early clinical experience
repaired functional ischemic mitral regurgitation. Circulation
with the Tricento bicaval valved stent for treatment of symptomatic
2005;112(9 Suppl):I453-7.
severe tricuspid regurgitation: a multicenter registry. Circ Cardiovasc
76. Van de Veire NR, Braun J, Delgado V, et al. Tricuspid annuloplasty Interv 2022;15:e011302.
prevents right ventricular dilatation and progression of tricuspid regur-
93. Estevez-Loureiro R, Sanchez-Recalde A, Amat-Santos IJ, et al. 6-
gitation in patients with tricuspid annular dilatation undergoing mitral
month outcomes of the tricvalve system in patients with tricuspid
valve repair. J Thorac Cardiovasc Surg 2011;141:1431-9.
regurgitation: the TRICUS EURO study. JACC Cardiovasc Interv
77. Brescia AA, Ward ST, Watt TMF, et al. Outcomes of guideline-directed 2022;15:1366-77.
concomitant annuloplasty for functional tricuspid regurgitation. Ann
94. Toyama K, Ayabe K, Kar S, et al. Postprocedural changes of tricuspid
Thorac Surg 2020;109:1227-32.
regurgitation after MitraClip therapy for mitral regurgitation. Am J
78. Gammie JS, Chu MWA, Falk V, et al. Concomitant tricuspid repair in Cardiol 2017;120:857-61.
patients with degenerative mitral regurgitation. N Engl J Med
95. Schueler R, Ozturk C, Sinning JM, et al. Impact of baseline tricuspid
2022;386:327-39.
regurgitation on long-term clinical outcomes and survival after inter-
79. Badhwar V, Rankin JS, He M, et al. Performing concomitant tricuspid ventional edge-to-edge repair for mitral regurgitation. Clin Res Cardiol
valve repair at the time of mitral valve operations is not associated with 2017;106:350-8.
increased operative mortality. Ann Thorac Surg 2017;103:587-93.
96. Mehr M, Karam N, Taramasso M, et al. Combined tricuspid and mitral
80. Tam DY, Tran A, Mazine A, et al. Tricuspid valve intervention at the versus isolated mitral valve repair for severe MR and TR: an analysis
time of mitral valve surgery: a meta-analysis. Interact Cardiovasc Thorac from the TriValve and TRAMI registries. JACC Cardiovasc Interv
Surg 2019;29:193-200. 2020;13:543-50.
81. Chikwe J, Itagaki S, Anyanwu A, Adams DH. Impact of concomitant 97. Sisinni A, Taramasso M, Praz F, et al. Concomitant transcatheter edge-
tricuspid annuloplasty on tricuspid regurgitation, right ventricular to-edge treatment of secondary tricuspid and mitral regurgitation: an
function, and pulmonary artery hypertension after repair of mitral valve expert opinion. JACC Cardiovasc Interv 2023;16:127-39.
prolapse. J Am Coll Cardiol 2015;65:1931-8.
98. Calabro P, Gragnano F, Niccoli G, et al. Antithrombotic therapy in
82. Ragnarsson S, Taha A, Nielsen SJ, et al. Pacemaker implantation patients undergoing transcatheter interventions for structural heart dis-
following tricuspid valve annuloplasty. JTCVS Open 2023;16:276-89. ease. Circulation 2021;144:1323-43.
83. Mar PL, Angus CR, Kabra R, et al. Perioperative predictors of perma- 99. Webb JG, Chuang AM, Meier D, et al. Transcatheter tricuspid valve
nent pacing and long-term dependence following tricuspid valve sur- replacement with the EVOQUE system: 1-year outcomes of a multi-
gery: a multicentre analysis. Europace 2017;19:1988-93. center, first-in-human experience. JACC Cardiovasc Interv 2022;15:
481-91.
84. Besler C, Blazek S, Rommel KP, et al. Combined mitral and tricuspid
versus isolated mitral valve transcatheter edge-to-edge repair in patients 100. McDonagh TA, Metra M, Adamo M, et al. 2021 ESC guidelines for
with symptomatic valve regurgitation at high surgical risk. JACC Car- the diagnosis and treatment of acute and chronic heart failure. Eur
diovasc Interv 2018;11:1142-51. Heart J 2021;42:3599-726.
85. Mehr M, Taramasso M, Besler C, et al. 1-year outcomes after edge-to- 101. Ren QW, Li XL, Fang J, et al. The prevalence, predictors, and prognosis
edge valve repair for symptomatic tricuspid regurgitation: results from of tricuspid regurgitation in stage B and C heart failure with preserved
the TriValve Registry. JACC Cardiovasc Interv 2019;12:1451-61. ejection fraction. ESC Heart Fail 2020;7:4051-60.
Volume 40 2024
102. Messika-Zeitoun D, Verta P, Gregson J, et al. Impact of tricuspid 105. Hagemeyer D, Ali FM, Ong G, Fam NP. The role of intracardiac
regurgitation on survival in patients with heart failure: a large electronic echocardiography in percutaneous tricuspid intervention: a new ICE
health record patient-level database analysis. Eur J Heart Fail 2020;22: age. Interv Cardiol Clin 2022;11:103-12.
1803-13.
106. Curio J, Abulgasim K, Kasner M, et al. Intracardiac echocardiography to
enable successful edge-to-edge transcatheter tricuspid valve repair in
103. Anker SD, Butler J, Filippatos G, et al. Empagliflozin in heart failure
patients with insufficient TEE quality. Clin Hemorheol Microcirc
with a preserved ejection fraction. N Engl J Med 2021;385:1451-61.
2020;76:199-210.
104. Solomon SD, McMurray JJV, Claggett B, et al. Dapagliflozin in heart 107. Davidson CJ, Abramson S, Smith RL, et al. Transcatheter tricuspid
failure with mildly reduced or preserved ejection fraction. N Engl J Med repair with the use of 4-dimensional intracardiac echocardiography.
2022;387:1089-98. JACC Cardiovasc Imaging 2022;15:533-8.

2024 Insuficiencia Tricuspidea

Uploaded by

Copyright:

Available Formats

2024 Insuficiencia Tricuspidea

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

2024 Insuficiencia Tricuspidea

Uploaded by

Copyright:

Available Formats

Canadian Journal of Cardiology 40 (2024) 185e200

Epidemiology to the TV annulus.22 The diagnosis can be made non-

Table 5. Currently available intracardiac echocardiography catheters and their characteristics

17. Badano LP, Muraru D, Enriquez-Sarano M. Assessment of functional

You might also like