New ACC Consensus Document Helps Clinicians Navigate Issues Around TR

Tricuspid regurgitation (TR) has been the subject of intense research in recent years, leading to the approval of two new transcatheter therapies, and a new expert consensus decision pathway from the American College of Cardiology (ACC) intends to help clinicians make sense of the rapidly evolving field.

With a focus on patients with secondary TR in the chronic setting, the document covers all aspects of management from initial evaluation to long-term follow-up, with detailed discussions of medical, surgical, and transcatheter treatment options.

There was need for this “clinician-focused” document, Dharam Kumbhani, MD (UT Southwestern Medical Center, Dallas, TX), a member of the writing committee, told TCTMD, because of all that has been happening in the tricuspid space.

Along with trials leading to the US Food and Drug Administration approvals of the TriClip (Abbott) for tricuspid transcatheter edge-to-edge repair (T-TEER) and the Evoque device (Edwards Lifesciences) for transcatheter tricuspid valve replacement (TTVR), TR research has advanced in other areas, including classification schemes for TR etiology and severity, prognostic risk scores, imaging techniques, and indications for surgery.

Kumbhani said that at an ACC roundtable a few years ago, “the feeling was that it would be helpful to have . . . a fairly comprehensive document that can speak to all the challenges that are involved with both the evaluation, the diagnostic part, as well as the management of these patients.”

Timely Diagnosis

The first part of the pathway, published online this week in JACC, with the writing committee chaired by Patrick O’Gara, MD (Brigham and Women’s Hospital, Boston, MA), focuses on the recognition, diagnosis, and assessment of TR, with imaging experts tasked with determining the etiology, mechanism, and severity. Transthoracic echocardiography (TTE) is the key imaging modality for evaluation, although the document highlights the role of more advanced techniques, like cardiac magnetic resonance imaging and cardiac CT, as well.

The authors also detail key adjunctive features, like right heart size and function, that should be considered, as well as the natural history of TR, which can go undetected for some time before it’s clinically recognized. They include models for assessing 1- and 3-year risks of all-cause mortality.

“The first message is it’s very important to have an accurate diagnosis of tricuspid regurgitation,” Kumbhani said. He underscored the necessity of “understanding the mechanism, understanding the severity, and then understanding all the associated aspects,” such as the extent of involvement of the right ventricle, liver, and kidney.

Treatment Options

There are no disease-modifying therapies with specific indications for treating TR, but the magnitude of TR can be eased by treating heart failure (HF) due to left-sided heart disease and atrial fibrillation (AF), the experts note.

There are sections on use of diuretics, guideline-directed medical therapy (GDMT) for underlying disease, and pulmonary vasodilators, as well as on therapeutic considerations for RV failure, AF, and TR related to cardiac implantable electronic devices (CIEDs).

The document also covers the consequences of progressive TR and RV dysfunction, issues around cardiorenal and cardiohepatic syndromes, and referral to advanced HF teams.

There is much discussion of options for surgical and transcatheter treatment of TR, the latter including not only T-TEER and TTVR, but also annuloplasty and heterotopic caval valve implantation.

The authors point out that certain variables can be used to indicate that T-TEER or TTVR may be preferred over the other. Having septal-lateral coaptation gaps > 7 mm or more than three TV leaflets or scallops, for instance, may favor TTVR, whereas the presence of advanced renal function or an inability to take anticoagulation may favor T-TEER.

“Most patients actually end up not needing a procedure,” Kumbhani said about the TV program at his center. “They’re either medically managed or a lot of times they’re sort of so far advanced that they probably need palliative care inputs.”

There is a role for the transcatheter therapies for patients in between those two types of populations, he added. “I don’t envision that this would be used indiscriminately, because TR is very prevalent. I think it just depends on really having a great understanding of the mechanism and where the patient is on that spectrum with the TR.”

Regardless of the type of treatment, there is an emphasis on the importance of working in multidisciplinary heart teams. In the context of TR, those might include a valve cardiologist, heart failure and imaging experts, interventional cardiologists, valve surgeons, cardiac anesthesiologists, electrophysiologists, nurses and advanced practice providers, and potentially others, like liver, kidney, and pulmonary experts.

The writing committee “acknowledges how multidisciplinary the management of TR needs to be,” Kumbhani said.

He pointed out that this decision pathway is not meant to be used as a fuller practice guideline, but as “more of a supportive document for physicians about how one might disentangle all the various complexities in this field.”

The document ends with 10 issues clinicians should consider when caring for a patient with TR and these, the authors say, “should serve as a bridge” to the next iteration of the US valvular heart disease guidelines, which were last updated in 2020. Updated European guidelines for valve disease came out late last month.