Top Things to Know: The Tricuspid Valve: A Review of Pathology, Imaging and Current Treatment Options
Published: April 25, 2024
Prepared by Nkechinyere Ijioma, MD
- Moderate or severe tricuspid regurgitation has an age-and sex-adjusted prevalence of 0.55% in the United States, with a higher incidence in women and older patients. Patients with moderate or severe tricuspid regurgitation have an observed survival of 10.2% at 15 years.
- There are anatomical variations of the tricuspid valve apparatus. The classic anatomy consists of three tricuspid valve leaflets (Type I). Anatomic variations include the presence of two leaflets (Type II), four functional leaflets (type III) or greater than four leaflets (Type IV).
- The etiology of tricuspid regurgitation can be classified as either primary tricuspid regurgitation i.e., due to structural abnormalities of the valve or secondary (functional) tricuspid regurgitation i.e., due to dilation of either the atrium or ventricle. Cardiovascular implantable electronic device interference with the tricuspid apparatus can also lead to tricuspid regurgitation.
- Severe tricuspid regurgitation can be asymptomatic - early in the disease course, and later progress to symptoms of central venous congestion, right heart failure and eventual cardiorenal syndrome and cardiac cirrhosis. Physical exam findings and invasive hemodynamics are useful tools in the assessment of patients with tricuspid regurgitation.
- Primary tricuspid regurgitation causes right heart volume overload which often leads to concomitant annular dilation. Prolonged pulmonary hypertension in secondary tricuspid regurgitation leads to several structural changes including within the right ventricle.
- Transthoracic echocardiography and transesophageal echocardiography play a crucial role in tricuspid valve assessment and intervention planning, and it is important to recognize the different echocardiography views, the role of biplane, 3D echocardiography with multiplanar reconstruction and intracardiac echocardiography in ensuring complete visualization and assessment of the tricuspid apparatus and tricuspid regurgitation severity.
- Cardiac computed tomography provides useful information about the venous system for the large bore delivery catheters used in transcatheter valve procedures and cardiac magnetic resonance imaging is useful if there are concerns regarding echocardiography underestimation of the severity of tricuspid regurgitation or right ventricular dysfunction.
- The mainstay treatment for symptomatic tricuspid valve disease is medical management to treat volume overload and slow the progression of right ventricular failure. In addition to diuretics, medications should address the primary etiology in primary tricuspid regurgitation, address the underlying cardiomyopathy/heart failure in secondary tricuspid regurgitation, the ensuing pulmonary hypertension, or resultant structural complications such as atrial fibrillation.
- Two types of tricuspid valve surgery exist: a) tricuspid repair or b) tricuspid replacement.
- The optimal transcatheter tricuspid device is predicated on the individual patient’s clinical and anatomical characteristics. There is insufficient data regarding the long-term durability of transcatheter tricuspid valve interventions and no guidelines to determine which patient is best suited for transcatheter tricuspid valve repair or replacement – hence the need for clinical trials and registry participation.
Citation
Davidson LJ, Tang GHL, Ho EC, Fudim M, Frisoli T, Camaj A, Bowers MT, Masri SC, Atluri P, Chikwe J, Mason PJ, Kovacic JC, Dangas GD; on behalf of the American Heart Association Interventional Committee of the Council on Clinical Cardiology; Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation; Council on Cardiovascular Surgery and Anesthesia; and Council on Cardiovascular and Stroke Nursing. The tricuspid value:a review of pathology, imaging, and current treatment options: a scientific statement from the American Heart Association. Circulation. Published online April 25, 2024. doi: 10.1161/CIR.0000000000001232