Management of Secondary Tricuspid and Mitral Regurgitation

Understanding the Mechanism

The American College of Cardiology and European Heart Society recognize that secondary regurgitation occurs due to ventricular remodeling and annular dilatation, not valve pathology itself, with mitral regurgitation resulting from left ventricular dilation and tricuspid regurgitation from right ventricular pressure/volume overload 1, 2
Atrial fibrillation is present in 70-88% of patients with severe tricuspid regurgitation and causes progressive annular dilatation independent of ventricular dysfunction, with the European Heart Society noting that AF-induced annular remodeling is a major determinant of secondary tricuspid regurgitation 4

The American College of Cardiology recommends quantifying mitral regurgitation severity using effective regurgitant orifice area, regurgitant volume, vena contracta width, and left atrial/ventricular dimensions, with severe mitral regurgitation defined as an effective regurgitant orifice area ≥0.4 cm² or regurgitant volume ≥60 mL 1
The European Heart Society suggests quantifying tricuspid regurgitation severity using vena contracta ≥7 mm, effective regurgitant orifice area ≥0.4 cm², regurgitant volume ≥45 mL, hepatic vein systolic flow reversal, and right heart chamber dilation, with severe tricuspid regurgitation defined as a vena contracta ≥7 mm or effective regurgitant orifice area ≥0.4 cm² 3, 5

The American College of Cardiology and European Heart Society recommend optimizing guideline-directed medical therapy for the underlying condition, such as left ventricular dysfunction or atrial fibrillation, before considering surgical intervention, with a focus on neurohormonal antagonists, cardiac resynchronization therapy, and coronary revascularization as needed 1, 5
The European Heart Society suggests using loop diuretics for symptom relief from congestion, adding aldosterone antagonists for volume management, and implementing rhythm control strategies if atrial fibrillation is present, with the goal of reducing symptoms and slowing disease progression 5

The American College of Cardiology and European Heart Society recommend considering mitral valve surgery for severe secondary mitral regurgitation with symptoms despite optimal medical therapy, with outcomes less favorable than primary mitral regurgitation 1
The European Heart Society strongly recommends tricuspid valve repair for patients with mild, moderate, or greater functional tricuspid regurgitation undergoing left-sided valve surgery, with a focus on preventing progression of tricuspid regurgitation and improving right ventricular function 6, 5

The European Heart Society recommends regular surveillance with serial echocardiography every 6-12 months to assess progression of regurgitation severity, ventricular dimensions, and ventricular function, with a focus on tracking tricuspid annular diameter progression and assessing right ventricular function deterioration 5, 4