Management of Severe Mitral Regurgitation and Tricuspid Regurgitation with Pulmonary Arterial Hypertension

Initial Management

The American College of Cardiology recommends surgical intervention with combined mitral valve repair/replacement and tricuspid valve repair for patients with severe mitral regurgitation and severe tricuspid regurgitation with severe pulmonary arterial hypertension 1, 2, 3
Diuretics are essential for managing volume overload and reducing right-sided heart failure symptoms in patients with severe tricuspid regurgitation and pulmonary arterial hypertension 4, 5
Medical therapies to reduce pulmonary artery pressures should be considered in patients with severe functional tricuspid regurgitation and pulmonary arterial hypertension before and after surgical intervention 6, 2

The American College of Cardiology strongly recommends tricuspid valve surgery for patients with severe tricuspid regurgitation who are undergoing left-sided valve surgery (Class I recommendation) 2, 5
Mitral valve repair is preferred over mitral valve replacement when technically feasible, particularly for primary mitral regurgitation involving the posterior leaflet 1, 7
For patients with severe secondary mitral regurgitation and tricuspid regurgitation undergoing surgery, concomitant repair of both valves should be performed 1, 3

Comprehensive evaluation with transthoracic echocardiography is essential to assess valve anatomy, severity of regurgitation, chamber sizes, and estimate pulmonary artery pressure 1, 6
Invasive measurement of pulmonary artery pressures and pulmonary vascular resistance is useful when clinical and noninvasive data are discordant 1, 4
Assessment of right ventricular function is critical, as severe right ventricular dysfunction may increase surgical risk and impact long-term outcomes 2

For severe mitral regurgitation, mitral valve repair is recommended for symptomatic patients with left ventricular ejection fraction >30% (Class I) 1, 6
For severe tricuspid regurgitation, tricuspid valve repair with annuloplasty is preferred over replacement when feasible 2, 3
Patients with severe tricuspid regurgitation and signs of right-sided heart failure should undergo tricuspid valve surgery even if the pulmonary arterial hypertension is severe 2, 5

Continued medical therapy for pulmonary arterial hypertension is often necessary after valve surgery, as pulmonary arterial hypertension may not completely resolve despite correction of valvular lesions 4, 7
Regular follow-up with echocardiography is essential to monitor valve function, ventricular remodeling, and pulmonary pressures 7

Early intervention before the development of irreversible right ventricular dysfunction may improve long-term outcomes 2, 5
The presence of both severe mitral regurgitation and severe tricuspid regurgitation with pulmonary arterial hypertension indicates advanced disease with worse prognosis if left untreated 7