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Tricuspid valve disease: diagnosis, prognosis and management of a rapidly evolving field

Abstract

Tricuspid valve disease, and particularly tricuspid regurgitation, is a highly prevalent condition with a complex pathophysiology and long-term adverse consequences. Although historically neglected, tricuspid valve disease has gained increasing recognition, with important advances in the assessment and management of this disorder over the past 2 decades. Surgical treatment remains the standard of care, but it continues to have one of the the highest death rates among all cardiac valve-related procedures, and a broad range of patients still do not receive effective therapy for tricuspid valve disease in contemporary clinical practice. Therefore, several alternative, less-invasive technologies for treating patients with severe, native tricuspid valve disease at high surgical risk have been developed in the past decade, with promising early results. This Review summarizes key findings and highlights the latest developments in the diagnosis and management framework that are transforming clinical practice in the complex field of tricuspid valve disease.

Key points

  • Tricuspid regurgitation is common in patients with chronic heart failure but is vastly undertreated, and its incidence is increasing, particularly among older patients with transtricuspid leads, right ventricular dysfunction or previous left-sided valve surgery.

  • Isolated tricuspid valve surgery remains rare and is associated with high in-hospital mortality, particularly in patients with previous left-sided valve surgery or initial tricuspid valve repair.

  • Comprehensive, multimodality imaging with novel quantification methods for severity assessment might improve the timely selection of those patients with meaningful clinical benefit after tricuspid valve interventions.

  • Concomitant surgical repair of tricuspid annular dilatation at the time of left-sided valve surgery is likely to become the standard of practice.

  • Three ongoing clinical trials will provide definite results on the benefit of prophylactic tricuspid valve repair during mitral valve surgery.

  • Early feasibility and safety data of emerging transcatheter therapies for tricuspid valve repair and replacement are a landmark step forward in tricuspid valve disease management; long-term durability and clinical outcomes need to be addressed in future trials.

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Fig. 1: Surgical tricuspid valve annuloplasty using an incomplete semi-rigid prosthetic ring.
Fig. 2: Transcatheter tricuspid valve repair therapies: coaptation devices.
Fig. 3: Transcatheter tricuspid valve repair therapies: annuloplasty devices.
Fig. 4: Transcatheter tricuspid valve repair therapies: heterotopic CAVI.
Fig. 5: Transcatheter tricuspid valve replacement.

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Acknowledgements

L.A. has received support from a grant from the Fundación Alfonso Martin Escudero. J.R.-C. holds the Canadian Research Chair ‘Fondation Famille Jacques Larivière’ for the Development of Structural Heart Disease Interventions.

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All authors researched the data for the article, provided substantial contributions to discussions of its content, wrote the article and undertook review and/or editing of the manuscript before submission.

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Correspondence to Josep Rodés-Cabau.

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M.T. is a consultant for 4TECH, Abbott Vascular, Boston Scientific and CoreMedic and has received speaker honoraria from Edwards Lifesciences. J.R.-C. has received institutional research grants from Edwards Lifesciences. L.A. declares no competing interests.

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Asmarats, L., Taramasso, M. & Rodés-Cabau, J. Tricuspid valve disease: diagnosis, prognosis and management of a rapidly evolving field. Nat Rev Cardiol 16, 538–554 (2019). https://doi.org/10.1038/s41569-019-0186-1

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