Isolated Tricuspid Regurgitation: How to Recognize It and When Surgery Is Needed

In isolated tricuspid regurgitation, the condition is caused by improper closure of the valve’s own anatomical structures, without involvement of other heart valves, due to:

• congenital diseases (Ebstein anomaly, Marfan syndrome);
• rheumatic fever;
• bacterial endocarditis;
• chest trauma;
• pacemaker leads;
• radiotherapy;
• carcinoid syndrome.

Among these causes, the most common are bacterial endocarditis (a condition that particularly affects people who use intravenous drugs), chest trauma (especially following road traffic accidents), and cases related to the placement of leads for pacemaker implantation.

By contrast, in most cases, tricuspid valve regurgitation develops secondary to mitral valve disease which, at an advanced stage, can also cause deterioration of the tricuspid valve due to dilation of the valve annulus. In these cases, it can almost always be corrected with reconstructive surgery using annuloplasty, which reduces the size of the dilated annulus.

In its early stages, isolated tricuspid regurgitation usually causes no symptoms and is often detected incidentally during echocardiographic screening. This initial absence of symptoms can be problematic because diagnosis is often made only after the disease has been present for a long time, by which point cardiac function may have deteriorated, particularly that of the right ventricle and right atrium.

Later, symptoms may include:

• shortness of breath during physical exertion;
• palpitations;
• subsequently, edema (swelling) of the ankles and feet.

An examination by a primary care physician may detect a heart murmur at an early stage and lead to referral to a cardiologist, who will perform an echocardiogram. This is the most effective test both for diagnosing tricuspid regurgitation and assessing its severity, helping to determine whether surgical treatment is indicated.

Early diagnosis can prevent deterioration of the heart’s structures, particularly the right ventricle and right atrium, and the resulting development of arrhythmias, such as atrial fibrillation, and heart failure.

Once severe tricuspid regurgitation has been diagnosed, the surgical procedure of choice (gold standard) is tricuspid valve repair or replacement.

In most cases, the most commonly used technique is annuloplasty, which involves implanting a prosthetic ring to tighten and reshape the valve, thereby correcting the regurgitation.

“In the past, we published a series of 6 cases of post-traumatic isolated tricuspid regurgitation in which annular dilation was associated with rupture of either the chordae tendineae or the papillary muscle, all structures that help maintain proper valve closure. In every case, we performed annuloplasty combined with either the implantation of artificial chordae tendineae or reimplantation of the papillary muscle,” explains the cardiac surgeon.

Tricuspid Valve Replacement with a Biological Prosthesis

When the tricuspid valve is severely damaged by an infectious process, such as bacterial endocarditis, or by chest trauma that has caused irreparable valve damage, or when a pacemaker lead has severely damaged the valve leaflets, the only remaining option is valve replacement with a prosthesis.

The biological prosthesis is the preferred option, as mechanical valves carry a high risk of thrombosis because of the low pressures in the right chambers of the heart.

“Recently, our center treated 2 cases of isolated tricuspid valve regurgitation. The first involved degeneration of a prosthetic valve following previous replacement with a bioprosthesis for endocarditis treated 11 years earlier. The second involved tricuspid regurgitation that developed after chest trauma in a road traffic accident, which was also complicated by the need for pacemaker implantation.

In both cases, for the first time in Brescia and among the first cases in Italy, we implanted a latest-generation bioprosthetic valve in the tricuspid position, a valve normally used in the mitral position. At present, there is no dedicated tricuspid bioprosthesis, so in these 2 cases the use of this innovative bioprosthesis, made from bovine pericardial tissue treated with a special anti-calcification technology, proved to be an ideal solution. This approach allowed us to use anticoagulant therapy for only 3 months before discontinuing it permanently.

In the past, the main limitation of bioprosthetic valves was their limited durability. One distinctive feature of the valve used in these cases, however, is its longevity, which is estimated at up to 20 years. This is considered particularly important for this patient population, which is generally relatively young,” emphasizes the specialist.

Medical Treatment for Older Patients

Only in very elderly patients and when the right ventricle is severely compromised, making surgery impossible, is medical treatment with diuretics or percutaneous transcatheter techniques considered.

These procedures are performed by inserting a catheter through the femoral vein in the groin and advancing it to the tricuspid valve. The most commonly used approach is the TriClip technique, in which one or more clips are positioned via the catheter along the free edges of the tricuspid valve leaflets, bringing them together in the center and significantly reducing blood regurgitation.

Isolated tricuspid valve regurgitation is an uncommon but particularly insidious heart condition because it can remain asymptomatic for a long time and is often discovered during an echocardiographic screening examination. This delay in diagnosis can lead to deterioration of cardiac function, with arrhythmias such as atrial fibrillation, and heart failure, sometimes progressing to the point where surgery is no longer possible.

The key message, therefore, is that a follow-up echocardiogram can be particularly useful, especially after chest trauma or pacemaker implantation, which are among the causes of this condition.

The use of latest-generation bioprosthetic valves made with patented biological tissue provides excellent long-term durability while allowing patients to remain free from long-term anticoagulant therapy.