Echocardiographic Assessment and Clinical Management of Tricuspid Regurgitation

Tricuspid Regurgitation in Left Ventricular Systolic Dysfunction: Marker or Target?

Far from being historically considered a primary healthcare problem, tricuspid regurgitation (TR) has recently gained much attention from the scientific community. In fact, in the last years, robust evidence has emerged regarding the epidemiological impact of TR, whose prevalence seems to be similar to that of other valvulopathies, such as aortic stenosis, with an estimated up to 4% of people >75 years affected by at least moderate TR in the United States, and up to 23% among patients suffering from heart failure with reduced ejection fraction. This recurrent coexistence of left ventricular systolic dysfunction (LVSD) and TR is not surprising, considered the multiple etiologies of tricuspid valve disease. TR can complicate heart failure mostly as a functional disease, because of pulmonary hypertension (PH), subsequent to elevated left ventricular end-diastolic pressure, leading to right ventricular dilatation, and valve tethering. Moreover, the so-called "functional isolated" TR can occur, in the absence of PH, as a result of right atrial dilatation associated with atrial fibrillation, a common finding in patients with LVSD. Finally, TR can result as a iatrogenic consequence of transvalvular lead insertion, another frequent scenario in this cohort of patients. Nonetheless, despite the significant coincidence of these two conditions, their mutual relation, and the independent prognostic role of TR is still a matter of debate. Whether significant TR is just a marker for advanced left-heart disease, or a crucial potential therapeutical target, remains unclear. Aim of the authors in this review is to present an update concerning the epidemiological features and the clinical burden of TR in the context of LVSD, its prognostic value, and the potential benefit for early tricuspid intervention in patients affected by contemporary TR and LVSD.

Prevalence, Echocardiographic Correlations, and Clinical Outcome of Tricuspid Regurgitation in Patients with Significant Left Ventricular Dysfunction

PURPOSE

We initiated this study to evaluate the prevalence and clinical significance of tricuspid regurgitation in patients with left ventricular dysfunction.

METHODS

A single-center analysis of all echocardiographic studies between 2000 and 2013 was performed. Patients with ejection fraction <35% were included, and those with mechanical valves, mitral stenosis, or significant aortic valve pathology were excluded. Patients were grouped based on tricuspid regurgitation severity (nonsignificant, moderate, and severe). Demographic and echocardiographic findings and survival were compared.

RESULTS

The study included 3943 patients (74% male, age 69 ± 14 years); 70% had nonsignificant, 24% had moderate, and 6% had severe tricuspid regurgitation. In a multivariate model, tricuspid regurgitation was independently associated with older age (odds ratio [OR] 1.009; 95% confidence interval [CI], 1.001-1.017; P = .022), female sex (OR 1.644; 95% CI, 1.329-2.035; P < .001), atrial fibrillation (OR 1.764; 95% CI, 1.429-2.134; P < .001), tricuspid regurgitation gradient (OR 1.051; 95% CI, 1.045-1.058; P < .001 per mm Hg), right ventricular dysfunction (OR 3.492; 95% CI, 2.870-4.248; P < .001), left atrial area (cm², OR 1.031; 95% CI, 1.013-1.049; P < .001), mitral regurgitation severity (P < .001), and lack of hypertension (OR 0.760; 95% CI, 0.616-0.936; P = .010) or obesity (OR 0.583; 95% CI, 0.427-0.796; P < .001). Patients were followed for a median of 8.15 years (interquartile range 4.75-11.42). Median survival was 4.88 years for nonsignificant, 2.3 years for moderate, and 1.6 years for patients with severe tricuspid regurgitation, significantly associated with tricuspid regurgitation severity (hazard ratio 1.513; 95% CI, 1.383-1.656 for moderate, hazard ratio 1.857; 95% CI, 1.606-2.148 for severe tricuspid regurgitation; P < .001), the association persisted after multiple adjustments.

CONCLUSIONS

Significant tricuspid regurgitation is common in patients with left ventricular dysfunction. It is linked to various cardiac pathologies and independently associated with increased mortality.

Evaluation and Management of Right-Sided Heart Failure: A Scientific Statement From the American Heart Association

Background and Purpose:

The diverse causes of right-sided heart failure (RHF) include, among others, primary cardiomyopathies with right ventricular (RV) involvement, RV ischemia and infarction, volume loading caused by cardiac lesions associated with congenital heart disease and valvular pathologies, and pressure loading resulting from pulmonic stenosis or pulmonary hypertension from a variety of causes, including left-sided heart disease. Progressive RV dysfunction in these disease states is associated with increased morbidity and mortality. The purpose of this scientific statement is to provide guidance on the assessment and management of RHF.

Methods:

The writing group used systematic literature reviews, published translational and clinical studies, clinical practice guidelines, and expert opinion/statements to summarize existing evidence and to identify areas of inadequacy requiring future research. The panel reviewed the most relevant adult medical literature excluding routine laboratory tests using MEDLINE, EMBASE, and Web of Science through September 2017. The document is organized and classified according to the American Heart Association to provide specific suggestions, considerations, or reference to contemporary clinical practice recommendations.

Results:

Chronic RHF is associated with decreased exercise tolerance, poor functional capacity, decreased cardiac output and progressive end-organ damage (caused by a combination of end-organ venous congestion and underperfusion), and cachexia resulting from poor absorption of nutrients, as well as a systemic proinflammatory state. It is the principal cause of death in patients with pulmonary arterial hypertension. Similarly, acute RHF is associated with hemodynamic instability and is the primary cause of death in patients presenting with massive pulmonary embolism, RV myocardial infarction, and postcardiotomy shock associated with cardiac surgery. Functional assessment of the right side of the heart can be hindered by its complex geometry. Multiple hemodynamic and biochemical markers are associated with worsening RHF and can serve to guide clinical assessment and therapeutic decision making. Pharmacological and mechanical interventions targeting isolated acute and chronic RHF have not been well investigated. Specific therapies promoting stabilization and recovery of RV function are lacking.

Conclusions:

RHF is a complex syndrome including diverse causes, pathways, and pathological processes. In this scientific statement, we review the causes and epidemiology of RV dysfunction and the pathophysiology of acute and chronic RHF and provide guidance for the management of the associated conditions leading to and caused by RHF.

The Role of Tricuspid Valve Surgery in the Late Management of Tetralogy of Fallot

While surgical repair of tetralogy of Fallot (TOF) is generally associated with good early outcomes, late complications affect long-term survival and may require reoperation. Pulmonary regurgitation (PR) and tricuspid regurgitation (TR) may increase the risk of arrhythmias, reduced cardiac function, and sudden death. Tricuspid valve function can be compromised secondarily in the setting of PR or directly as a result of injury or alteration of the valve related to the original TOF repair. This article reviews the etiologic mechanisms, pathophysiological implications, and surgical interventions for TR. Effective management following TOF repair requires consideration of TR to optimize late outcomes.