Tricuspid regurgitation and stenosis — structured written assessment

SAQ 1 (10 marks)

Practice scenario. A 68-year-old man with severe primary degenerative mitral regurgitation is listed for mitral valve repair. TTE shows moderate secondary TR, graded as progressive TR (Stage B) by ACC/AHA 2020 criteria, with a tricuspid annulus end-diastolic diameter of 43 mm. He is in sinus rhythm and has never had signs or symptoms of right-sided heart failure.^[1][3]

1. Give the ESC/EACTS 2025 row on the tricuspid valve at his operation, with its class, level and stated aim, and what ESC/EACTS 2025 means by TV surgery. (2)^[1]
2. Give the ACC/AHA 2020 row that applies to him, with COR and LOE. (2)^[3]
3. What does ESC/EACTS 2025 say happens to moderate TR left uncorrected at left-sided valve surgery, and what risk of concomitant repair must be weighed? (2)^[1]
4. Describe the design and main results of the CTSN randomised trial of concomitant tricuspid annuloplasty. (2)^[17]
5. Give two ACC/AHA/HRS 2018 rows on pacing at tricuspid valve surgery, with COR and LOE. (2)^[8]

Model answers — SAQ 1

1. In patients with left-sided valvular heart disease requiring surgery, concomitant TV repair should be considered in patients with moderate primary or secondary TR, to avoid progression of TR and RV remodelling (Class IIa, Level B) (1 mark).^[1] In Recommendation Table 9, TV surgery means valve repair whenever possible (1 mark).^[1]
2. In progressive TR (Stage B) undergoing left-sided valve surgery, tricuspid valve surgery can be beneficial with tricuspid annular dilation (end-diastolic diameter >4.0 cm) or prior signs and symptoms of right-sided HF; his 43 mm annulus meets the first limb (1 mark).^[3] COR 2a, LOE B-NR (1 mark).^[3]
3. Mild TR with significant annular dilatation or moderate TR left uncorrected at left-sided valve surgery progresses in about one-quarter of patients and is associated with worse outcome (1 mark).^[1] Concomitant TV repair has been associated with a higher risk of conduction disturbances needing a pacemaker (up to 14%), with potential negative effects on longer-term outcomes (1 mark).^[1]
4. 401 patients undergoing mitral-valve surgery for degenerative mitral regurgitation were randomised to surgery with or without tricuspid annuloplasty; the primary 2-year end point combined reoperation for TR, progression of TR by two grades or to severe TR, and death (1 mark).^[17] Primary-end-point events were fewer with annuloplasty (3.9% vs 10.2%; relative risk 0.37), but permanent pacemaker implantation was more frequent (14.1% vs 2.5%) (1 mark).^[17]
5. In patients undergoing tricuspid valve surgery, routine placement of temporary epicardial pacing wires is recommended (COR 1, LOE C-LD) (1 mark).^[8] In patients undergoing tricuspid valve replacement or tricuspid repair with high risk for postoperative AV block, intraoperative placement of permanent epicardial leads is reasonable (COR 2a, LOE C-LD); or: new postoperative SND or AV block with symptoms or haemodynamic instability that does not resolve after tricuspid valve surgery calls for permanent pacing before discharge (COR 1, LOE B-NR) (1 mark for either).^[8]

SAQ 2 (10 marks)

Practice scenario. A 52-year-old woman with rheumatic heart disease has ascites and ankle oedema. TTE shows thickened tricuspid leaflets with commissural fusion, a mean diastolic transvalvular gradient of 7 mmHg at a heart rate of 72 bpm and mild TR. She is in sinus rhythm, has no other indication for anticoagulation and needs no left-sided valve intervention.^[1]

1. How does ESC/EACTS 2025 define severe TS, and which findings indicate rheumatic involvement? (2)^[1]
2. Give the ESC/EACTS 2025 row on intervention that applies to her, with class and level, and what surgery usually means in that row. (2)^[1]
3. When can percutaneous balloon valvuloplasty be attempted under ESC/EACTS 2025, and what limits it in rheumatic tricuspid disease? (2)^[1]
4. If she needs replacement, which prosthesis type does ESC/EACTS 2025 prefer and why, and what does it say about later degeneration? (2)^[1]
5. Give the ESC/EACTS 2025 description of medical therapy for TS, and its row on anticoagulation in the first months after a surgical tricuspid bioprosthesis. (2)^[1]

Model answers — SAQ 2

1. A mean diastolic transvalvular gradient of >5 mmHg at a normal heart rate indicates severe TS (1 mark).^[1] Leaflet thickening, with or without calcification, and commissural fusion are pathognomonic of rheumatic involvement (1 mark).^[1]
2. Surgery is recommended in symptomatic patients with severe TS (Class I, Level C) (1 mark).^[1] In that row, surgery usually means TV replacement (1 mark).^[1]
3. Footnote d says percutaneous balloon valvuloplasty can be attempted as a first approach if TS is isolated; the text adds it can be an option, with very limited data, in selected TS without relevant TR or with combined rheumatic mitral and tricuspid disease (1 mark).^[1] Unlike rheumatic MS, rheumatic tricuspid disease more often presents as combined stenosis and regurgitation, which limits valvuloplasty (1 mark).^[1]
4. Biological valves have shown adequate mid- and long-term results and are preferred over mechanical valves because of high thrombogenicity in the low-pressure system (1 mark).^[1] If a bioprosthesis degenerates, transcatheter valve-in-valve procedures are good alternatives to re-replacement (1 mark).^[1]
5. Medical therapy is a bridge to surgical or transcatheter intervention; intensive sodium restriction with diuretics can improve symptoms and hepatic congestion (1 mark).^[1] A VKA should be considered for the first 3 months after surgical implantation of a mitral or tricuspid bioprosthesis in patients without a clear indication for OAC (Class IIa, Level B) (1 mark).^[1]