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Otto et al 2020 ACC/AHA Guideline for the Management of Valvular Heart Disease

Circulation. 2021;143:e72–e227. DOI: 10.1161/CIR.0000000000000923 February 2, 2021 e133 CLINICAL STATEMENTS AND GUIDELINES

8.2.3 Timing of Intervention

Recommendations for Timing of Intervention Referenced studies that support the recommendations are summarized in Online Data Supplement 32. COR LOE Recommendations

1 B-NR 1.  In patients with severe TR (Stages C and D) undergoing left-sided valve surgery, tricuspid valve surgery is recommended.1–8

2a B-NR 2.  In patients with progressive TR (Stage B) undergoing left-sided valve surgery, tricuspid valve surgery can be beneficial in the context of either 1) tricuspid annular dilation (tricuspid annulus end diastolic diameter >4.0 cm) or 2) prior signs and symptoms of right-sided HF.3–10

2a B-NR 3.  In patients with signs and symptoms of right-sided HF and severe primary TR (Stage D), isolated tricuspid valve surgery can be beneficial to reduce symptoms and recurrent hospitalizations.11–14

2a B-NR 4.  In patients with signs and symptoms of rightsided HF and severe isolated secondary TR attributable to annular dilation (in the absence of pulmonary hypertension or left-sided disease) who are poorly responsive to medical therapy (Stage D), isolated tricuspid valve surgery can be beneficial to reduce symptoms and recurrent hospitalizations.11,12,15–19

2b C-LD 5.  In asymptomatic patients with severe primary TR (Stage C) and progressive RV dilation or systolic dysfunction, isolated tricuspid valve surgery may be considered.12,20

2b B-NR 6.  In patients with signs and symptoms of rightsided HF and severe TR (Stage D) who have undergone previous left-sided valve surgery, reoperation with isolated tricuspid valve surgery may be considered in the absence of severe pulmonary hypertension or severe RV systolic dysfunction.1,2,11,18

Synopsis

Treatment of secondary TR is targeted at pulmonary hypertension or myocardial disease. Surgical treatment is performed for selected patients with TR at the time of surgery for left-sided valve lesions to treat severe TR (Stages C and D) and to prevent later development of severe TR in patients with progressive TR (Stage B). Surgical intervention should be considered for selected patients with isolated TR (either primary TR or secondary TR attributable to annular dilation in the absence of pulmonary hypertension or dilated cardiomyopathy). Intervention for severe isolated TR had a high reported operative mortality rate (up to 8% to 20%), but most of these interventions were performed after end-organ damage.21 However, outcomes of patients with severe primary TR are poor with medical management. There is renewed interest in earlier surgery for patients with severe isolated TR before the onset of severe RV dysfunction or end-organ damage.2,11,12,18,19,22 This interest is attributable to 1) an increasing number of patients presenting with right-sided HF from isolated TR,23–25 2) more advanced surgical techniques, and 3) better selection processes, resulting in a lower operative risk with documented improvement in symptoms (Figure 10).11,12,15–19

There is growing interest in the development of catheter-based therapies for these patients with severe isolated TR.26,27

Recommendation-Specific Supportive Text

1.	 Severe TR of either a primary or secondary etiology may not improve predictably after treatment of the left-sided valve lesion and reduction of RV afterload; as such, severe TR should be addressed as part of the index procedure.1,2,28–31 Reoperation for severe, isolated TR after left-sided valve surgery is associated with a perioperative mortality rate of 10% to 25%.1,29 Tricuspid valve repair does not add appreciably to the risks of surgery.1,2,28–31 There has been a significant increase in the number of tricuspid valve repairs performed for this indication over the past decade. Tricuspid valve repair is preferable to replacement, but replacement may be necessary if there is marked dilation of the annulus or intrinsic disease of the tricuspid leaflets.28,31 Observational data have shown a lower operative risk with tricuspid valve repair than with replacement, but this may be related to patient selection, given that the latter would be inserted in patients with a severely dilated annulus and abnormal leaflets to prevent recurrent or residual regurgitation. The risks and benefits of tricuspid valve operation should be carefully considered in the presence of severe RV systolic dysfunction or irreversible pulmonary hypertension because of the possibility of RV failure after operation. 2.	 Left uncorrected at the time of left-sided valve surgery, mild or moderate degrees of secondary TR may progress over time in approximately 25% of patients and result in reduced long-term functional outcome and survival.32 Risk factors for persistence or progression of TR include tricuspid annulus dilation (>40 mm diameter or 21 mm/m2 diameter indexed to body surface area on preoperative TTE measured at end diastole; >70 mm diameter on direct intraoperative measurement of the intercomissural distance), degree of RV dysfunction or remodeling, leaflet tethering height, pulmonary artery hypertension, AF, and intra-annular RV pacemaker or implantable cardioverter-defibrillator leads.3–10,33–36 Several observational studies and one prospective RCT have demonstrated the benefit of tricuspid repair at the time of mitral valve surgery for progressive TR (Stage B) with tricuspid annulus dilation on echocardiographic and functional parameters, although data on outcomes such as survival and major adverse events are lacking.3–10,33–35 Because

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