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February 2, 2021 Circulation. 2021;143:e72–e227. DOI: 10.1161/CIR.0000000000000923 e134

CLINICAL STATEMENTS AND GUIDELINES Otto et al 2020 ACC/AHA Guideline for the Management of Valvular Heart Disease

the severity of TR may be dynamic, dependent on the preload and pulmonary pressures, a past history of signs or symptoms of right-sided HF indicates the propensity to develop more severe TR and should be considered an indication for concomitant tricuspid valve repair. 3.	 In patients with symptomatic severe primary TR, reduction or elimination of the regurgitant volume load by tricuspid valve surgery can alleviate systemic venous and hepatic congestion and decrease reliance on diuretics.11,12,20 Patients with severe congestive hepatopathy may also benefit from surgery to prevent irreversible cirrhosis of the liver. Quality and duration of long-term survival are related to residual RV function. In patients with severe symptomatic primary TR from either device leads or endomyocardial biopsy, TR develops rapidly, and surgery can be done before the onset of RV dysfunction.11,37 Correction of symptomatic severe primary TR (Stage D) in patients without left-sided valve disease would preferentially be performed before the onset of significant RV dysfunction or end-organ damage. Randomized studies of early intervention are lacking, and the benefit might be limited by the risk of intervention, suboptimal reduction in TR severity, or suboptimal durability of currently available approaches to tricuspid valve repair and replacement. 4.	 There is now recognition that TR can develop in association with AF and annular dilation (a form of secondary TR).23–25 Notably, AF-related TR appears to represent a fundamentally different pathophysiology from other forms of secondary TR, with greater basal dilation and annular enlargement, as compared with the RV elongation with leaflet tethering seen in patients who have secondary TR caused by pulmonary hypertension or myocardial disease.24 These patients with AF-related TR have rapid progression of TR severity and right-sided chamber dilation. In appropriately selected symptomatic patients with AF-related severe TR, quality of life and symptoms can be improved by surgical intervention for TR. In patients undergoing intervention, overall outcomes are better in those without severe RV dysfunction or end-organ damage. Newer surgical techniques and a better selection process resulted in an acceptable operative mortality rate (<4% to 5%) for isolated TR in selected patients.2,11,12,15–19,22,38

5.	 The optimal timing of tricuspid valve surgery for asymptomatic or minimally symptomatic patients with severe primary TR has not been established. Extrapolation from limited experiences reported for patients with stable carcinoid heart disease and patients with a flail tricuspid leaflet, as well as application of the management principles adopted for patients with severe MR, suggest that serial assessments of RV size and function might trigger consideration of corrective surgery in selected patients with severe primary TR when a pattern of continued deterioration can be established and the surgical risk is considered acceptable.13,14 In otherwise healthy patients without other comorbidities, such as patients with severe TR attributable to trauma, the surgical risk associated with tricuspid valve operation is low (<1% to 2% operative mortality

Figure 10. Tricuspid regurgitation. Colors correspond to Table 2. GDMT indicates guideline-directed management and therapy; HF, heart failure; PAP, pulmonary artery pressure; PH, pulmonary hypertension; RV, right ventricular; TR, tricuspid regurgitation; and TV, tricuspid valve.

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