Assessment of Functional Tricuspid Regurgitation
Assessment of Functional Tricuspid Regurgitation
Functional tricuspid regurgitation (FTR) is characterized by structurally normal leaflets and is due to the deformation of the valvulo-ventricular complex. While mild FTR is frequent and usually benign, patients with severe FTR may develop progressive ventricular dysfunction and incur increased mortality. Therefore, FTR should not be ignored, should be appropriately diagnosed and quantified by Doppler echocardiography, and should be evaluated for corrective surgical procedures. At present, referral for surgical correction of FTR is often delayed until patients develop intractable heart failure. However, this strategy frequently translates in poor clinical outcome characterized by notable operative mortality and reduced long-term survival. Appropriate patient selection and proper timing for tricuspid valve (TV) repair or replacement are crucial for optimal outcome, but objective criteria for clinical decison-making remain poorly defined. In the present paper, we review the anatomy of the normal TV, the pathophysiology of FTR, the assessment of its severity and functional significance, and propose an algorithm for selecting patients for surgical treatment.
The aetiology of tricuspid regurgitation (TR) is generally divided into organic [with intrinsic tricuspid valve (TV) disease] and functional (FTR) in the absence of structural abnormalities of tricuspid leaflets (Table 1). Organic TR results from structural abnormalities of TV apparatus, may be congenital or acquired and accounts for only 8–10% of all severe TRs. Functional TR is a consequence of deformation of the TV apparatus, such as dilation and geometric deformation of tricuspid annulus (TA), and therefore the term 'secondary TR' is also used.
Functional TR is frequently caused by increased right ventricular (RV) afterload and it is associated with advanced stages of left-sided valve, myocardial or pulmonary diseases. In these patients, moderate or severe TR has a significant impact on their functional capacity and long-term survival, and surgical repair or replacement of the TV is the only corrective treatment presently available. However, operations for symptomatic FTR have the reputation for being high-risk procedures, particularly in candidates to redo surgery after previous correction of left-sided heart valve disease, and several investigators support a more aggressive, earlier surgical approach to FTR. Another issue making the clinical decision-making difficult is the notable rate of recurrence of FTR after surgical repair, which emphasizes the importance of a detailed anatomic diagnosis prior to making the decision of a repair vs. replacement approach.
Despite the general agreement regarding the need for appropriate patient selection and optimal timing of surgical treatment of FTR, there is a lack of objective criteria to guide clinicians in proper assessment of patients with FTR.
In this paper, we review the anatomy of the normal TV, the pathophysiology of FTR, the assessment of its severity and functional significance, and propose an algorithm for selecting patients for surgical treatment.
Abstract and Introduction
Abstract
Functional tricuspid regurgitation (FTR) is characterized by structurally normal leaflets and is due to the deformation of the valvulo-ventricular complex. While mild FTR is frequent and usually benign, patients with severe FTR may develop progressive ventricular dysfunction and incur increased mortality. Therefore, FTR should not be ignored, should be appropriately diagnosed and quantified by Doppler echocardiography, and should be evaluated for corrective surgical procedures. At present, referral for surgical correction of FTR is often delayed until patients develop intractable heart failure. However, this strategy frequently translates in poor clinical outcome characterized by notable operative mortality and reduced long-term survival. Appropriate patient selection and proper timing for tricuspid valve (TV) repair or replacement are crucial for optimal outcome, but objective criteria for clinical decison-making remain poorly defined. In the present paper, we review the anatomy of the normal TV, the pathophysiology of FTR, the assessment of its severity and functional significance, and propose an algorithm for selecting patients for surgical treatment.
Introduction
The aetiology of tricuspid regurgitation (TR) is generally divided into organic [with intrinsic tricuspid valve (TV) disease] and functional (FTR) in the absence of structural abnormalities of tricuspid leaflets (Table 1). Organic TR results from structural abnormalities of TV apparatus, may be congenital or acquired and accounts for only 8–10% of all severe TRs. Functional TR is a consequence of deformation of the TV apparatus, such as dilation and geometric deformation of tricuspid annulus (TA), and therefore the term 'secondary TR' is also used.
Functional TR is frequently caused by increased right ventricular (RV) afterload and it is associated with advanced stages of left-sided valve, myocardial or pulmonary diseases. In these patients, moderate or severe TR has a significant impact on their functional capacity and long-term survival, and surgical repair or replacement of the TV is the only corrective treatment presently available. However, operations for symptomatic FTR have the reputation for being high-risk procedures, particularly in candidates to redo surgery after previous correction of left-sided heart valve disease, and several investigators support a more aggressive, earlier surgical approach to FTR. Another issue making the clinical decision-making difficult is the notable rate of recurrence of FTR after surgical repair, which emphasizes the importance of a detailed anatomic diagnosis prior to making the decision of a repair vs. replacement approach.
Despite the general agreement regarding the need for appropriate patient selection and optimal timing of surgical treatment of FTR, there is a lack of objective criteria to guide clinicians in proper assessment of patients with FTR.
In this paper, we review the anatomy of the normal TV, the pathophysiology of FTR, the assessment of its severity and functional significance, and propose an algorithm for selecting patients for surgical treatment.
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