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11.2 Evaluation

Echocardiography is recommended to assess patients with TR45 and should include evaluation of severity and aetiology (including characterization of left-sided heart disease and, if applicable, CIED lead location and interaction with the valve apparatus), the impact of TR on the rightsided chambers (RV and RA size and function), and assessment of central venous (inferior vena cava) and pulmonary pressures. Transthoracic echocardiography provides sufficient diagnostic information in most patients. Transoesophageal echocardiography is necessary for when visualization of the TV apparatus. In candidates for an intervention, advanced techniques, such as strain analysis and 3D echocardiography, should also be applied when available. Assessment of TR severity should be ideally performed in euvolaemic status, with optimized pulmonary and systemic pressures, and based on an integrative approach considering multiple qualitative and quantitative parameters (Figure 15).45,693 A grading scheme extending beyond severe, including ‘massive’ and ‘torrential’ grades, has been proposed to refine TR reduction assessment after transcatheter interventions and has been used in several studies.694,695 Although this five-grade scale may be associated with a proportional increase in symptoms and event risk,694,695 an intervention should be considered without delay, as soon as TR is severe, with the aim of reducing TR to moderate or less.696,697 Echocardiographic assessment of the RV is challenging due to its complex geometry, imaging constraints, and the high dependency on loading conditions. When accurate measurements of RV size and function, as well as RV volume, are necessary for decision-making, CMR should be used because of its high accuracy and reproducibility.698,699 In Figure 15, upper limits of normal for different RV size parameters are provided to guide definition of RV dilatation and remodelling. In the setting of severe TR, RV function is often overestimated and therefore the most conservative/cautious thresholds are suggested for the currently used echocardiographic parameters to identify RV dysfunction at the earliest stage possible. Cut-off values for severe RV dysfunction are also provided to indicate high-risk or possibly futile interventions. Although robust validation is lacking, all these reference values are chosen based on large multicentre reports of normative data and outcomes.60,697,700–704 Echocardiography often underestimates pulmonary pressures in cases of severe TR.705 Right heart catheterization is therefore recommended in all candidates for an intervention to assess the haemodynamic consequences of TR on the RA and venous circulation (e.g. ventricularization of the RA pressure curves), measure end-diastolic RV pressure, and document volume overload. The assessment of pulmonary pressures and vascular resistance are key to exclude masked severe pre-capillary PH.706 RV–pulmonary artery coupling refers to the ability of the RV systolic performance to match a given pulmonary afterload maintaining adequate cardiac output, and can be measured invasively or approximated using echocardiography [i.e. tricuspid annular plane systolic excursion (TAPSE)/SPAP].707,708 RV–pulmonary artery uncoupling (low TAPSE/SPAP) occurs when sustained increases in afterload cannot be matched by RV contractile reserve and has been associated with poor prognosis in different HF conditions, including severe TR. Although not yet prospectively validated, this index may improve risk stratification. Electrocardiogram-gated CCT with dedicated protocols ensuring sufficient contrast enhancement of the right heart cavities provides detailed characterization of the RA, RV, and vena cava anatomy, the location of the right coronary artery, and is crucial to assess suitability and device sizing for several transcatheter interventions.689,697

Before any intervention is considered, careful evaluation of TR aetiology, disease stage (TR severity, RV and LV dysfunction, and PH), patient operative risk, and likelihood of recovery by a dedicated collaborative Heart Team is recommended (Figure 16). Dedicated clinical risk scores for TR patients have been described recently. The TRI-SCORE709 and the STS isolated TV risk calculator710 take into consideration clinical and echocardiographic signs of RV dysfunction, and secondary organ (particularly hepatic and renal) impairment. They both allow improved estimates of peri-procedural risk in patients with severe TR undergoing surgery and possibly help to avoid futile interventions.84,711 The importance of risk stratification was demonstrated in a recent registry analysis (n = 2413) comparing any interventions with conservative management. Early TV intervention (transcatheter valve repair or surgery) was associated with improved mid-term survival in patients with a low or intermediate TRI-SCORE (up to 5 points), while patients with a high TRI-SCORE (≥6) did not derive any benefit compared with conservative management.696 Moreover, isolated TV surgery (repair or replacement) improved survival at 10 years in patients with a low TRI-SCORE (≤3). The same benefit was observed in patients with an intermediate TRI-SCORE (4–5) after successful TV repair only.689,697,709 Patients with moderate or severe TR should be regularly followed up clinically and by echocardiography at least every 6 months.

11.3 Medical therapy

Patients with relevant TR should be first treated according to the assumed aetiology, including optimal HF treatment, pulmonary vasodilators for PH, and rhythm control for AF.339,693 In the case of HF symptoms, diuretics should be initiated in a stepwise approach,339 beginning with loop diuretics eventually combined with aldosterone antagonists, thiazide diuretics, and/or SGLT2is.712 However, according to current knowledge, medical therapy has very limited effect on the evolution of TR severity and none of these measures should delay evaluation of an intervention at an expert centre.713

11.4 Indications for intervention

11.4.1. Surgery Patients are often referred too late for surgery when significant RV and other organ failure have occurred. Isolated TV surgery has therefore been considered to be generally high risk, with in-hospital mortality rates of 8%–10% in several reports,714,715 but contemporary cohorts have demonstrated improved outcomes when patients are referred earlier and more effective techniques are used.716 Valve repair using an annuloplasty ring is preferred over replacement, whenever technically feasible, especially in low-risk patients with suitable anatomy.709 However, TV replacement may be necessary in cases of advanced disease with marked annular dilatation and leaflet tethering.688,717 For CIED-related TR, preparation of any entrapped tricuspid leaflet and possibly lead extraction with implantation of an epicardial system has been associated with improved TV function.688,717

ESC Guidelines                                                                                                                                                                                          4683

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