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9.1 Evaluation

Echocardiography provides the most useful information. Tricuspid stenosis is often overlooked and requires careful evaluation. Echocardiographic evaluation of valve anatomy and subvalvular apparatus is important to assess valve reparability. No generally accepted grading of tricuspid stenosis severity exists, but a mean echocardiographic transvalvular gradient >_5 mmHg at normal heart rate is considered indicative of significant tricuspid stenosis.362

9.2 Indications for intervention

Intervention on the tricuspid valve is usually performed concomitantly during procedures for left-sided valve disease in patients who are symptomatic despite medical therapy. Although the lack of pliable leaflet tissue is a main limitation for valve repair, the choice between repair and replacement depends on anatomy and surgical expertise. Owing to satisfactory long-term durability, biological prostheses are usually preferred over mechanical valves, which have a high risk of thrombosis.451 Percutaneous tricuspid balloon valvuloplasty has been performed in a limited number of cases, either alone or in combination with PMC. It frequently induces significant regurgitation and long-term results are lacking.452 It can be considered in rare cases with anatomically suitable valves, when tricuspid stenosis is isolated or additional mitral stenosis can also be treated interventionally (see recommendations on indications for PMC and mitral valve surgery in clinically significant mitral stenosis in section 7).

9.3 Medical therapy

Diuretics are useful in the presence of heart failure symptoms but are of limited long-term efficacy.

10 Combined and multiple-valve

diseases

Significant stenosis and regurgitation can be found on the same valve. Disease of multiple valves may be encountered in several conditions, particularly in rheumatic and congenital heart disease, but also less frequently in degenerative valve disease. There is a lack of data on combined or multiple-valve disease.453460 This does not allow for evidence-based recommendations. The general principles for the management of combined or multiple-valve disease are as follows: • When either stenosis or regurgitation is predominant, management follows the recommendations concerning the predominant VHD. When the severity of both stenosis and regurgitation is balanced, indications for interventions should be based on symptoms and objective consequences rather than on the indices of severity of stenosis or regurgitation.453456 In this setting, Doppler pressure gradient reflects the global haemodynamic burden (stenosis and regurgitation) of the valve lesion.453 • Besides the separate assessment of each valve lesion, it is necessary to consider the interaction between the different valve lesions. As an illustration, associated mitral regurgitation may Recommendations on indications for intervention in tricuspid valve disease

Recommendations Classa Levelb

Recommendations on tricuspid stenosis Surgery is recommended in symptomatic patients with severe tricuspid stenosis.c I C Surgery is recommended in patients with severe tricuspid stenosis undergoing left-sided valve intervention.d I C Recommendations on primary tricuspid regurgitation Surgery is recommended in patients with severe primary tricuspid regurgitation undergoing leftsided valve surgery. I C Surgery is recommended in symptomatic patients with isolated severe primary tricuspid regurgitation without severe RV dysfunction. I C Surgery should be considered in patients with moderate primary tricuspid regurgitation undergoing left-sided valve surgery. IIa C Surgery should be considered in asymptomatic or mildly symptomatic patients with isolated severe primary tricuspid regurgitation and RV dilatation who are appropriate for surgery. IIa C Recommendations on secondary tricuspid regurgitation Surgery is recommended in patients with severe secondary tricuspid regurgitation undergoing left-sided valve surgery.423427 I B Surgery should be considered in patients with mild or moderate secondary tricuspid regurgitation with a dilated annulus (>_40 mm or >21 mm/m2 by 2D echocardiography) undergoing left-sided valve surgery.423,425427 IIa B Surgery should be considered in patients with severe secondary tricuspid regurgitation (with or without previous left-sided surgery) who are symptomatic or have RV dilatation, in the absence of severe RV or LV dysfunction and severe pulmonary vascular disease/hypertension.418,433 e IIa B Transcatheter treatment of symptomatic secondary severe tricuspid regurgitation may be considered in inoperable patients at a Heart Valve Centre with expertise in the treatment of tricuspid valve disease.f IIb C

2D = two-dimensional; LV = left ventricle/left ventricular; PMC = percutaneous mitral commissurotomy; RV = right ventricle/right ventricular. aClass of recommendation. bLevel of evidence. cPercutaneous balloon valvuloplasty can be attempted as a first approach if tricuspid stenosis is isolated. dPercutaneous balloon valvuloplasty can be attempted if PMC can be performed on the mitral valve. eIn patients with previous surgery recurrent left-sided valve dysfunction needs to be excluded. fTranscatheter treatment can be performed according to Heart Team at experienced valve centres in anatomically eligible patients in whom improvement of quality of life or survival can be expected. ESC/EACTS 2021

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