Tricuspid Regurgitation: What You Need to Know

Podcast Transcript

Announcer:

Welcome to Love Your Heart, brought to you by Cleveland Clinic's Sydell and Arnold Miller Family Heart, Vascular and Thoracic Institute. These podcasts will help you learn more about your heart, thoracic and vascular systems, ways to stay healthy, and information about diseases and treatment options. Enjoy.

Tom Kai Ming Wang, MBChB, MD:

Hello everyone. My name is Dr. Tom Wang. I'm a staff cardiologist here at the Cleveland Clinic in the section of Cardiovascular Imaging and Department of Cardiovascular Medicine, as well as assistant professor at the Cleveland Clinic Lerner College of Medicine.

Tom Kai Ming Wang, MBChB, MD:

So today I want to be discussing with you regarding a condition called tricuspid regurgitation, which is increasingly recognized and is associated with adverse outcomes if you do not treat it appropriately. So tricuspid regurgitation is a condition of the tricuspid valve. So it's one of the four valves inside the heart. It is on the right side, which is the side that drains the blood that has run out of oxygen from the veins back into the heart to then go to the lungs to get oxygen again. So the tricuspid valve is between the two chambers on the right side of the heart: the right atrium, which is the filling chamber, as well as the right ventricle, which is the more muscular, pumping chamber that gets the blood to the lungs.

Now, why has tricuspid valve not getting as much attention as other valves? It's because the left side of valves, the aortic and mitral valve, have more proven therapies and a lot of effective procedures and are probably more common overall than tricuspid regurgitation. However, tricuspid regurgitation is also important now, as is discussed earlier.

Tom Kai Ming Wang, MBChB, MD:

So what does valve regurgitation mean? So there's two problems that can happen to heart valves that lead to problems. One is that the valve leaflets do not open properly and becomes thickened and sometimes calcified and leads to obstruction to blood flow. And that's called stenosis, which is not what we're discussing today. But the other problem is that the valve leaflets when they close, there's some gaps when it closes, and therefore leads to leakage of blood flow going in the wrong direction. And that's called tricuspid regurgitation. So that's why it's important to look at leaky heart valves to determine what can be causing it. Because if the blood flow is going in the wrong direction, then it can cause bad outcomes on the heart muscle itself and also to how you feel.

Tom Kai Ming Wang, MBChB, MD:

So the next question is what causes tricuspid regurgitation? And there's many different causes, but 95% of cases, it's what we call secondary tricuspid regurgitation, which means there's something else wrong with the heart that leads to the leakage of the valve, whereas only about 5% of cases where the leaflets themselves are actually damaged. So secondary causes of tricuspid regurgitation includes anything else wrong with the heart on the left side. So if you've got some aortic valve issue, mitral valve issue, if you have heart failure or weakened heart muscle, or even if you've had abnormal heart rhythms like atrial fibrillation or blocked heart artery disease, all of those things can lead to secondary tricuspid regurgitation. The other cause for secondary tricuspid regurgitation is if you have chronic lung disease from lung damage such as smoking-related lung disease and other lung diseases that increases the pressure in the lungs, that then leads to tricuspid regurgitation.

Tom Kai Ming Wang, MBChB, MD:

What are the causes of primary tricuspid regurgitation, which means the valve leaflets themselves are damaged? This can include infection of the valve leaflets like endocarditis, rheumatic fever and rheumatic heart disease, if it's just sort of age wear and tear and degenerative changes, if you've got a pacemaker that's impinging on the leaflet itself and other rarer causes like carcinoid, cancers, congenital or inherited causes and so on.

Tom Kai Ming Wang, MBChB, MD:

So next we want to know about what are the symptoms of tricuspid regurgitation that should alert you to maybe thinking about that you may have this condition? So unfortunately, actually many people have no symptoms and the tricuspid regurgitation is detected when we assess them for a variety of other reasons and we find it incidentally. But if you were going to feel unwell with tricuspid regurgitation, the main symptoms are you'll start to feel a bit more fatigued. You might feel short of breath and notice that you can't exercise as much as you can, that you are noticing a decrease in the exercise tolerance. You might get swelling, which can be in the legs often or sometimes in the abdomen or anywhere else in the body, and you might feel a bit of bloating or reduced appetite, nausea and so on.

Tom Kai Ming Wang, MBChB, MD:

Now these symptoms are often very non-specific, so you should see a doctor and even a cardiologist to get checked out to see what type of heart condition you may have. And sometimes it could even be a lung condition. So when you come to see a heart doctor regarding tricuspid regurgitation or leaky heart valves, one of the first things the doctor's going to do for you is to do some imaging tests to look at how much leakage there is and if there's indeed leakage at all.

Tom Kai Ming Wang, MBChB, MD:

So one of the first tests that you are going to get is a heart ultrasound scan where the sonographer or technician will put a probe on your chest, usually with a cold gel and using that they can assess all your heart chambers as well as all your heart valves to see how your heart function is doing and whether your valves have any narrowing or leakage in them. And based on that they can assess the severity of your leaking heart valve and also what's causing the leaking heart valve and how is that impacting on your heart chamber's size and function. So for example, if it's becoming more dilated or if your pump function is reduced, then that might suggest that there's more severity in the leakage of the heart valve. Other imaging tests that the cardiologist might order may include a transesophageal echo. So this involves putting a probe down the esophagus, a bit like an endoscopy, and you're generally sedated for that, but that gives us much clearer images of the valve leaflets to see what's causing it and how bad the leakage is.

Tom Kai Ming Wang, MBChB, MD:

You could get a test called a cardiac MRI, which you go into a big scanner and you lie down for about half an hour to an hour where they run through many sequences to assess your heart size and function as well as the leaflets. And also you could get a CT scan, which is a scan that is quicker, five to 10 minutes, which may involve contrast injection, which will help us plan for procedures, whether it's a operation or transcatheter procedure. Occasionally you might get a cath procedure as well, which is a test to look at your heart arteries and also measure the pressures inside your heart to see whether it's suitable that you might need a procedure or not.

Tom Kai Ming Wang, MBChB, MD:

So the last but also important question that is asked is how do we treat tricuspid regurgitation? And in many cases, before getting to a severe stage, medications is all that is needed. So for example, if you're becoming more and more short of breath and swelling, then you need to be given medications to help you take the fluid off and pass more urine. So these are the diuretic medications. If you have conditions like heart failure or weak heart muscle, you should be on medications that improve the heart function. If you have, for example, a blocked heart artery disease, then you might need procedures to treat that such as stents or bypass surgery. If you have abnormal heart rhythms which often contribute to leaky heart valves, then you might need medications to either slow your heart rate down, keep your heart rhythm in the normal rhythm, or even ablation procedures that can try and get rid of that heart rhythm for you, such as atrial fibrillation.

Tom Kai Ming Wang, MBChB, MD:

Once we move beyond that, so if you have quite severe leakage of the heart valve and medications aren't sufficient to control either your symptoms or the leak, then that's where we start to consider an operation which can involve an open heart operation or in selected cases, the more recent developed transcatheter procedures. So if you have an open heart operation, that is just like any other standard open heart surgery. It might involve just the tricuspid valve for the leak or whether you might have also other valves that need to be fixed or the heart arteries that need to be fixed at the same time. But it'll be the standard open heart surgery that you'll be put under general anesthetic, so you'll be put to sleep. You'll be on the cardiopulmonary bypass machine, which will do the heart pumping and oxygen delivery for your body for you. And then it will be usually three to four hours to try and do the operation. You can expect that you'll be intensive care unit usually one to two days after the procedure and in hospital for about five to seven days after the procedure, assuming that everything goes well.

Tom Kai Ming Wang, MBChB, MD:

And this is where that tricuspid regurgitation surgery really needs special expertise because there's a vast difference in outcomes depending on where your surgery is performed. We know that for isolated tricuspid surgery for example, it's a very high-risk procedure and the chance of dying or something bad happening to you may be as high as eight to 10% if you just take an average surgical center in the US or around the world. Whereas at Cleveland Clinic, the risk of an adverse outcome of that happening is much lower at around 3% and therefore this is why many patients choose to come here to have this operation because it's a highly technical operation and not often performed. So you want it to be done at a very high expertise and volume center. And here we will manage the surgery. We'll try to do tricuspid valve repair as much as possible to avoid a valve replacement to improve the outcomes and also operate as early as we can so that we know that you're not too sick to have the operation.

However, for some patients, they might be further down the line before they find out they have tricuspid regurgitation and need a procedure. This can still be safely done here at the Cleveland Clinic, either with an operation or sometimes, if the risk is truly too high, then we have to consider transcatheter procedures. So these are procedures where we don't have to do an open heart surgery. We don't have to cut through the sternum, but we can try and get to your heart, often through your groin, so blood vessels through your groin and with catheters to go up the veins and into the heart to then fix the valve that way.

Tom Kai Ming Wang, MBChB, MD:

And there's a few options, both that are on the market as well as in the clinical trials that are currently underway done here at the Cleveland Clinic, which may involve, for example, putting a clip to bring the valve leaflets closer together. It can involve putting in devices that bring in the annulus so that it brings again from the outside to bring the valve closer together to reduce the leak. It can involve procedures that put devices into your veins that drain back into the heart so that the leakage of the valve doesn't affect the other organs. And also valve replacement procedures where they put in a new valve through a catheter into the heart to try and reduce the leak. And each of these have various degrees of success, but we have building a large experience here at the Clinic to try and improve the outcomes in those which surgery is deemed too high risk or inappropriate.

Tom Kai Ming Wang, MBChB, MD:

So in summary for you to understand tricuspid regurgitation, it's one of the right side of the heart valves of which there's a significant leak in it, and it can be associated with symptoms and adverse outcomes, which is why you need to be assessed by a cardiologist using a variety of imaging techniques from the cardiac ultrasound or the echo and you might need an MRI or a CT scan. And then the management will involve at the minimum medications to try and improve and reduce the degree of leak targeting the causes of tricuspid regurgitation. And then if you do have severe leakage, then you might require an operation or a transcatheter procedure to improve your outcomes. Thank you for your attention.

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