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11.4.1.1 Patients without indication for left-sided valve

surgery In patients with severe TR but without the need for left-sided valve surgery, surgical intervention is recommended in operable symptomatic patients with primary TR (Figure 17; Recommendation Table 9).718 Furthermore, it should be considered in symptomatic patients with secondary TR, or in asymptomatic patients with primary or secondary TR and signs of RV dilatation or RV function deterioration.719 However, patients with severe LV/RV dysfunction or PH do not qualify due to high operative risk.84,686,720

11.4.1.2 Patients with indication for left-sided valve surgery

Severe primary or secondary TR is unlikely to improve after isolated surgical treatment of left-sided valve disease, and reoperation for TR treatment is associated with high peri-operative mortality.721 Therefore, TV surgery is recommended at the time of the index procedure. Mild TR with associated significant annular dilatation or moderate TR, if left uncorrected at the time of left-sided valve surgery, will progress in approximately one-quarter of patients and is associated with worse outcome.690,722 In patients with moderate TR, TV repair annuloplasty during MV surgery should be considered, because large retrospective studies723,724 and two recent RCTs have shown beneficial effects on TR progression and RV remodelling over time.725,726

However, no effects on mortality, HF events, or reoperation were observed in the repair group.725,727 Concomitant TV repair has also been associated with a higher risk of conduction disturbances requiring pacemaker implantation (up to 14%),725,728 with potential negative impacts on longer-term outcomes.729,730 In patients with mild TR and annular dilatation (≥40 mm or >21 mm/m2) undergoing left-sided valve surgery, previous observational studies have demonstrated a benefit of concomitant TV repair in terms of TR progression723,724 and RV function,731 and a trend towards improved long-term survival.724 However, a subanalysis of a recent RCT did not identify any difference in the progression of TR or other outcomes in this category of patients

   
  	

 


	  


  


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Figure 16 Stepwise evaluation of patients with tricuspid regurgitation. RV, right ventricle/right ventricular. aSee Supplementary data online, Table S4.

ESC Guidelines                                                                                                                                                                                          4685

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