J Cardiovasc Ultrasound.  2013 Mar;21(1):1-9. 10.4250/jcu.2013.21.1.1.

Tricuspid Regurgitation: Clinical Importance and Its Optimal Surgical Timing

• Kim HK
• Lee SP
• Kim YJ
• Sohn DW

• KMID: 1428369
• DOI: http://doi.org/10.4250/jcu.2013.21.1.1

Abstract

Tricuspid regurgitation (TR) has long been neglected based on the false belief that it is substantially rare in prevalence and is not so important in determining prognosis. Recent consecutive publications refuted this concept surrounding TR, and now we are contemplating this entity from different point of view. In this review, we mainly focus on isolated form of severe TR. In our daily clinical practice, however, patients with problems in more than one valve are more frequently encountered. Hence, we briefly touch on the results of severe TR surgery with or without left side valve operations here and there, as well.

Keyword

Tricuspid regurgitation; Echocardiography; Hemoglobin; Functional capacity

MeSH Terms

Echocardiography
Hemoglobins
Humans
Prevalence
Prognosis
Tricuspid Valve Insufficiency
Hemoglobins

Figure

• 

  Fig. 1 Event-free cumulative survival rates according to the presence or absence of late development of significant tricuspid regurgitation (TR). Note that survival curve begins to diverge approximately 130 months after left-sided valve surgery, highlighting that more than 10 years of careful clinical and echocardiographic follow-up is clearly indicated to evaluate whether or not significant TR is developed after left-sided valve surgery. Reprinted, with permission, from Am Heart J 2008;155:732-7.3)

• 

  Fig. 2 On preoperative two-dimensional (A) and Doppler (B) echocardiography, there was no doubt that severe tricuspid regurgitation (TR) is present in this woman. The problem was that even after tricuspid annuloplasty with an annular ring, severe TR was still there and was not gone (C and D). In this example, we can understand that mechanisms other than tricuspid annular dilation may be present in accounting for development of functional TR (A and B: Preoperative. C and D: Postoperative).

Reference

1. Nihoyannopoulos P. Tricuspid valvectomy following tricuspid valve endocarditis on an intravenous drug addict. Heart. 2001. 86:144.

2. Kim HK, Kim YJ, Kim KI, Jo SH, Kim KB, Ahn H, Sohn DW, Oh BH, Lee MM, Park YB, Choi YS. Impact of the maze operation combined with left-sided valve surgery on the change in tricuspid regurgitation over time. Circulation. 2005. 112:9 Suppl. I14–I19.

3. Kwak JJ, Kim YJ, Kim MK, Kim HK, Park JS, Kim KH, Kim KB, Ahn H, Sohn DW, Oh BH, Park YB. Development of tricuspid regurgitation late after left-sided valve surgery: a single-center experience with long-term echocardiographic examinations. Am Heart J. 2008. 155:732–737.

4. Kim YJ, Kwon DA, Kim HK, Park JS, Hahn S, Kim KH, Kim KB, Sohn DW, Ahn H, Oh BH, Park YB. Determinants of surgical outcome in patients with isolated tricuspid regurgitation. Circulation. 2009. 120:1672–1678.

5. Kim JB, Jung SH, Choo SJ, Chung CH, Lee JW. Surgical outcomes of severe tricuspid regurgitation: predictors of adverse clinical outcomes. Heart. 2013. 99:181–187.

6. Topilsky Y, Khanna AD, Oh JK, Nishimura RA, Enriquez-Sarano M, Jeon YB, Sundt TM, Schaff HV, Park SJ. Preoperative factors associated with adverse outcome after tricuspid valve replacement. Circulation. 2011. 123:1929–1939.

7. Kim HK, Kim YJ, Park EA, Bae JS, Lee W, Kim KH, Kim KB, Sohn DW, Ahn H, Park JH, Park YB. Assessment of haemodynamic effects of surgical correction for severe functional tricuspid regurgitation: cardiac magnetic resonance imaging study. Eur Heart J. 2010. 31:1520–1528.

8. Groves PH, Lewis NP, Ikram S, Maire R, Hall RJ. Reduced exercise capacity in patients with tricuspid regurgitation after successful mitral valve replacement for rheumatic mitral valve disease. Br Heart J. 1991. 66:295–301.

9. Nath J, Foster E, Heidenreich PA. Impact of tricuspid regurgitation on long-term survival. J Am Coll Cardiol. 2004. 43:405–409.

10. Czer LS, Maurer G, Bolger A, DeRobertis M, Kleinman J, Gray RJ, Chaux A, Matloff JM. Tricuspid valve repair. Operative and follow-up evaluation by Doppler color flow mapping. J Thorac Cardiovasc Surg. 1989. 98:101–110. discussion 110-1.

11. Goldman ME, Guarino T, Fuster V, Mindich B. The necessity for tricuspid valve repair can be determined intraoperatively by two-dimensional echocardiography. J Thorac Cardiovasc Surg. 1987. 94:542–550.

12. Hannoush H, Fawzy ME, Stefadouros M, Moursi M, Chaudhary MA, Dunn B. Regression of significant tricuspid regurgitation after mitral balloon valvotomy for severe mitral stenosis. Am Heart J. 2004. 148:865–870.

13. McGrath LB, Gonzalez-Lavin L, Bailey BM, Grunkemeier GL, Fernandez J, Laub GW. Tricuspid valve operations in 530 patients. Twenty-five-year assessment of early and late phase events. J Thorac Cardiovasc Surg. 1990. 99:124–133.

14. Porter A, Shapira Y, Wurzel M, Sulkes J, Vaturi M, Adler Y, Sahar G, Sagie A. Tricuspid regurgitation late after mitral valve replacement: clinical and echocardiographic evaluation. J Heart Valve Dis. 1999. 8:57–62.

15. Je HG, Song H, Jung SH, Choo SJ, Song JM, Kang DH, Yun SC, Chung CH, Song JK, Lee JW. Impact of the Maze operation on the progression of mild functional tricuspid regurgitation. J Thorac Cardiovasc Surg. 2008. 136:1187–1192.

16. Matsuyama K, Matsumoto M, Sugita T, Nishizawa J, Tokuda Y, Matsuo T. Predictors of residual tricuspid regurgitation after mitral valve surgery. Ann Thorac Surg. 2003. 75:1826–1828.

17. Izumi C, Iga K, Konishi T. Progression of isolated tricuspid regurgitation late after mitral valve surgery for rheumatic mitral valve disease. J Heart Valve Dis. 2002. 11:353–356.

18. Stulak JM, Schaff HV, Dearani JA, Orszulak TA, Daly RC, Sundt TM 3rd. Restoration of sinus rhythm by the Maze procedure halts progression of tricuspid regurgitation after mitral surgery. Ann Thorac Surg. 2008. 86:40–44. discussion 44-5.

19. Ubago JL, Figueroa A, Ochoteco A, Colman T, Duran RM, Duran CG. Analysis of the amount of tricuspid valve anular dilatation required to produce functional tricuspid regurgitation. Am J Cardiol. 1983. 52:155–158.

20. Mikami T, Kudo T, Sakurai N, Sakamoto S, Tanabe Y, Yasuda H. Mechanisms for development of functional tricuspid regurgitation determined by pulsed Doppler and two-dimensional echocardiography. Am J Cardiol. 1984. 53:160–163.

21. Come PC, Riley MF. Tricuspid anular dilatation and failure of tricuspid leaflet coaptation in tricuspid regurgitation. Am J Cardiol. 1985. 55:599–601.

22. Fukuda S, Song JM, Gillinov AM, McCarthy PM, Daimon M, Kongsaerepong V, Thomas JD, Shiota T. Tricuspid valve tethering predicts residual tricuspid regurgitation after tricuspid annuloplasty. Circulation. 2005. 111:975–979.

23. Fukuda S, Gillinov AM, McCarthy PM, Stewart WJ, Song JM, Kihara T, Daimon M, Shin MS, Thomas JD, Shiota T. Determinants of recurrent or residual functional tricuspid regurgitation after tricuspid annuloplasty. Circulation. 2006. 114:1 Suppl. I582–I587.

24. Kim HK, Kim YJ, Park JS, Kim KH, Kim KB, Ahn H, Sohn DW, Oh BH, Park YB, Choi YS. Determinants of the severity of functional tricuspid regurgitation. Am J Cardiol. 2006. 98:236–242.

25. Min SY, Song JM, Kim JH, Jang MK, Kim YJ, Song H, Kim DH, Lee JW, Kang DH, Song JK. Geometric changes after tricuspid annuloplasty and predictors of residual tricuspid regurgitation: a real-time three-dimensional echocardiography study. Eur Heart J. 2010. 31:2871–2880.

26. Bonow RO, Carabello BA, Chatterjee K, de Leon AC Jr, Faxon DP, Freed MD, Gaasch WH, Lytle BW, Nishimura RA, O'Gara PT, O'Rourke RA, Otto CM, Shah PM, Shanewise JS. 2006 Writing Committee Members. American College of Cardiology/American Heart Association Task Force. 2008 Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease) endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation. 2008. 118:e523–e661.

27. Yang WI, Shim CY, Kang MK, Chang HJ, Chung N, Cho SY, Ha JW. Vena contracta width as a predictor of adverse outcomes in patients with severe isolated tricuspid regurgitation. J Am Soc Echocardiogr. 2011. 24:1013–1019.

28. Park K, Kim HK, Kim YJ, Cho GY, Kim KH, Kim KB, Sohn DW, Ahn H, Oh BH, Park YB. Incremental prognostic value of early postoperative right ventricular systolic function in patients undergoing surgery for isolated severe tricuspid regurgitation. Heart. 2011. 97:1319–1325.

29. Filsoufi F, Anyanwu AC, Salzberg SP, Frankel T, Cohn LH, Adams DH. Long-term outcomes of tricuspid valve replacement in the current era. Ann Thorac Surg. 2005. 80:845–850.

30. Vahanian A, Baumgartner H, Bax J, Butchart E, Dion R, Filippatos G, Flachskampf F, Hall R, Iung B, Kasprzak J, Nataf P, Tornos P, Torracca L, Wenink A. Task Force on the Management of Valvular Hearth Disease of the European Society of Cardiology. ESC Committee for Practice Guidelines. Guidelines on the management of valvular heart disease: The Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology. Eur Heart J. 2007. 28:230–268.

31. Kwon DA, Park JS, Chang HJ, Kim YJ, Sohn DW, Kim KB, Ahn H, Oh BH, Park YB, Choi YS. Prediction of outcome in patients undergoing surgery for severe tricuspid regurgitation following mitral valve surgery and role of tricuspid annular systolic velocity. Am J Cardiol. 2006. 98:659–661.

32. Haeck ML, Scherptong RW, Marsan NA, Holman ER, Schalij MJ, Bax JJ, Vliegen HW, Delgado V. Prognostic value of right ventricular longitudinal peak systolic strain in patients with pulmonary hypertension. Circ Cardiovasc Imaging. 2012. 5:628–636.

33. Kaul S, Tei C, Hopkins JM, Shah PM. Assessment of right ventricular function using two-dimensional echocardiography. Am Heart J. 1984. 107:526–531.

34. Forfia PR, Fisher MR, Mathai SC, Housten-Harris T, Hemnes AR, Borlaug BA, Chamera E, Corretti MC, Champion HC, Abraham TP, Girgis RE, Hassoun PM. Tricuspid annular displacement predicts survival in pulmonary hypertension. Am J Respir Crit Care Med. 2006. 174:1034–1041.

35. Dini FL, Fontanive P, Panicucci E, Andreini D, Chella P, De Tommasi SM. Prognostic significance of tricuspid annular motion and plasma NT-proBNP in patients with heart failure and moderate-to-severe functional mitral regurgitation. Eur J Heart Fail. 2008. 10:573–580.

36. Damy T, Kallvikbacka-Bennett A, Goode K, Khaleva O, Lewinter C, Hobkirk J, Nikitin NP, Dubois-Randé JL, Hittinger L, Clark AL, Cleland JG. Prevalence of, associations with, and prognostic value of tricuspid annular plane systolic excursion (TAPSE) among out-patients referred for the evaluation of heart failure. J Card Fail. 2012. 18:216–225.

37. Hsiao SH, Lin SK, Wang WC, Yang SH, Gin PL, Liu CP. Severe tricuspid regurgitation shows significant impact in the relationship among peak systolic tricuspid annular velocity, tricuspid annular plane systolic excursion, and right ventricular ejection fraction. J Am Soc Echocardiogr. 2006. 19:902–910.

38. Anand IS, Chandrashekhar Y, Ferrari R, Sarma R, Guleria R, Jindal SK, Wahi PL, Poole-Wilson PA, Harris P. Pathogenesis of congestive state in chronic obstructive pulmonary disease. Studies of body water and sodium, renal function, hemodynamics, and plasma hormones during edema and after recovery. Circulation. 1992. 86:12–21.

39. Anand IS, Kuskowski MA, Rector TS, Florea VG, Glazer RD, Hester A, Chiang YT, Aknay N, Maggioni AP, Opasich C, Latini R, Cohn JN. Anemia and change in hemoglobin over time related to mortality and morbidity in patients with chronic heart failure: results from Val-HeFT. Circulation. 2005. 112:1121–1127.

40. Go AS, Yang J, Ackerson LM, Lepper K, Robbins S, Massie BM, Shlipak MG. Hemoglobin level, chronic kidney disease, and the risks of death and hospitalization in adults with chronic heart failure: the Anemia in Chronic Heart Failure: Outcomes and Resource Utilization (ANCHOR) Study. Circulation. 2006. 113:2713–2723.

41. Choi DJ, Han S, Jeon ES, Cho MC, Kim JJ, Yoo BS, Shin MS, Seong IW, Ahn Y, Kang SM, Kim YJ, Kim HS, Chae SC, Oh BH, Lee MM, Ryu KH. KorHF Registry. Characteristics, outcomes and predictors of long-term mortality for patients hospitalized for acute heart failure: a report from the korean heart failure registry. Korean Circ J. 2011. 41:363–371.

42. Maeder MT, Khammy O, dos Remedios C, Kaye DM. Myocardial and systemic iron depletion in heart failure implications for anemia accompanying heart failure. J Am Coll Cardiol. 2011. 58:474–480.

43. Okonko DO, Mandal AK, Missouris CG, Poole-Wilson PA. Disordered iron homeostasis in chronic heart failure: prevalence, predictors, and relation to anemia, exercise capacity, and survival. J Am Coll Cardiol. 2011. 58:1241–1251.

44. Comin-Colet J, Lainscak M, Dickstein K, Filippatos GS, Johnson P, Lüscher TF, Mori C, Willenheimer R, Ponikowski P, Anker SD. The effect of intravenous ferric carboxymaltose on health-related quality of life in patients with chronic heart failure and iron deficiency: a subanalysis of the FAIR-HF study. Eur Heart J. 2013. 34:30–38.

45. Avni T, Leibovici L, Gafter-Gvili A. Iron supplementation for the treatment of chronic heart failure and iron deficiency: systematic review and meta-analysis. Eur J Heart Fail. 2012. 14:423–429.

46. Mukoyama M, Nakao K, Hosoda K, Suga S, Saito Y, Ogawa Y, Shirakami G, Jougasaki M, Obata K, Yasue H, et al. Brain natriuretic peptide as a novel cardiac hormone in humans. Evidence for an exquisite dual natriuretic peptide system, atrial natriuretic peptide and brain natriuretic peptide. J Clin Invest. 1991. 87:1402–1412.

47. Rademaker MT, Charles CJ, Espiner EA, Nicholls MG, Richards AM, Kosoglou T. Combined neutral endopeptidase and angiotensin-converting enzyme inhibition in heart failure: role of natriuretic peptides and angiotensin II. J Cardiovasc Pharmacol. 1998. 31:116–125.

48. Galiè N, Olschewski H, Oudiz RJ, Torres F, Frost A, Ghofrani HA, Badesch DB, McGoon MD, McLaughlin VV, Roecker EB, Gerber MJ, Dufton C, Wiens BL, Rubin LJ. Ambrisentan in Pulmonary Arterial Hypertension, Randomized, Double-Blind, Placebo-Controlled, Multicenter, Efficacy Studies (ARIES) Group. Ambrisentan for the treatment of pulmonary arterial hypertension: results of the ambrisentan in pulmonary arterial hypertension, randomized, double-blind, placebo-controlled, multicenter, efficacy (ARIES) study 1 and 2. Circulation. 2008. 117:3010–3019.

49. Detaint D, Messika-Zeitoun D, Avierinos JF, Scott C, Chen H, Burnett JC Jr, Enriquez-Sarano M. B-type natriuretic peptide in organic mitral regurgitation: determinants and impact on outcome. Circulation. 2005. 111:2391–2397.

50. Pizarro R, Bazzino OO, Oberti PF, Falconi M, Achilli F, Arias A, Krauss JG, Cagide AM. Prospective validation of the prognostic usefulness of brain natriuretic peptide in asymptomatic patients with chronic severe mitral regurgitation. J Am Coll Cardiol. 2009. 54:1099–1106.

51. Hwang IC, Kim YJ, Kim KH, Lee SP, Kim HK, Sohn DW, Oh BH, Park YB. Prognostic value of B-type natriuretic peptide in patients with chronic mitral regurgitation undergoing surgery: mid-term follow-up results. Eur J Cardiothorac Surg. 2013. 43:e1–e6.

52. Yoon CH, Zo JH, Kim YJ, Kim HK, Shine DH, Kim KH, Kim KB, Ahn H, Sohn DW, Oh BH, Park YB. B-type natriuretic Peptide in isolated severe tricuspid regurgitation: determinants and impact on outcome. J Cardiovasc Ultrasound. 2010. 18:139–145.

53. Gammie JS, O'Brien SM, Griffith BP, Ferguson TB, Peterson ED. Influence of hospital procedural volume on care process and mortality for patients undergoing elective surgery for mitral regurgitation. Circulation. 2007. 115:881–887.