Fig. 14.1
Electrocardiography
Fig. 14.2
(a, b) Showing dilated right atrium and right ventricle with interventricular septum bulged to the left. There is a severe tricuspid regurgitation due annular dilatation and restriction of septal leaflet. The insertion of the tricuspid leaflets looked further normal
In 2013 she was again presented with complaints of fatigue, dyspnea and some palpitations, with estimated NYHA class II a III. She had this time some signs of right-sided heart failure with elevated JVP and mild hepatomegaly. Cardiac auscultation revealed a 3/6 some rough systolic murmur at the 4th left sided intercostal spaces. There were no signs of ascites or peripheral edema. Her ECG showed sinus rhythm 66 bpm with frequent premature atrial extra systoles, PQ 182 ms, QRS width 102 ms and increased right precordial repolarisation abnormalities. Her echocardiography (Fig. 14.2a, b) showed severe RA and RV dilatation with diastolic D-sign of the interventricular septum at the parasternal short-axis view, and mobile intra-atrial septum. The RV function showed mild systolic dysfunction with TAPSE of 16 mm. There was again severe TR with a TR gradient of 24 m Hg with normal collapsing VCI of 18 mm. The patient was treated with low doses digoxin 0.0625 mg qd, bumetanide 1 mg bid, eplerenone 25 mg qd and bisoprolol 1.25 mg qd. Her case was discussed again in the heart team for redo surgery, but rejected due estimated low successful repair rate. Alternatively, the tricuspid valve could be replaced by a mechano-prothesis, but given the high long-term risk of complications, the redo surgery was postponed for the time being as long as the pharmacological treatment was sufficient for control of congestive symptoms. She was advised to do cardiac rehabilitation. At last follow-up in October, 2016, she was stable with some complaints of tiredness, but without any signs of heart failure. Her estimated functional NYHA class was II. Her ECG showed sinus rhythm 60 bpm, with signs of RV hypertrophy and secondary strain pattern.
Pharmacotherapy (See Fig. 14.3)
Lifestyle Advises
In patients with signs of fluid overload/congestion, mild salt (<5 g/day) and fluid restriction (1.5 or 2 L/day) is usually indicated, especially in patients needing high doses of loop diuretics and/or refractory congestion. The evidence in of these lifestyle advices is however far from conclusive [2].
Fig. 14.3
The approach for the pharmacological treatment of tricuspid valve diseases
Loop Diuretics
For patient with symptomatic heart failure and volume overload, the initial therapy is usually a loop diuretics like furosemide or bumetanide [3]. The usual starting dose for furosemide in our clinic is 40 mg qd (bumetanide 1 mg qd), but in more advanced heart failure patients with more severe elevated jugular venous pressure (JVP) , hepatomegaly, ascites and/or peripheral edema, twice daily dose is usually need. Albeit no maximal doses toe give, in case of failing oral daily doses above furosemide 500 mg orally (or bumetanide 10 mg), continuous intravenous are usually need. In cases of non-response of progressive deterioration of the renal function, additional low doses inotropes (e.g. dobutamine 3–5 μg/kg/min or enoximone 0.5–2 μg/kg/min) could be added.
In case of euvolemia, maintanence dose of diuretics should be minimalized, given potiential aggrevation of the neurohormonal stress, i.e. renine-angiotensine-aldosteron system, beside risks of gout, electrolyte disturbances and renal dysfunction.
Mineralocorticoid Receptor Antagonist
The clinical use of the mineralocorticoid receptor antagonist (MRA) spironolactone and eplerenone is in chronic HF is established with two landmark trials: RALES and EMPHASIS [4, 5]. The studies are however in predominantly, left-sided systolic HF patients. In predominant right-sided HF patients like in TR, the use of MRA based on clinical experience. The usual start doses for spironolactone is 12.5–25 mg with maintenance doses of 25–50 mg daily and for eplerenone 25–50 mg. In refractory heart failure patients and/or diuretic resistances, usually higher doses (>100 mg) are needed. The common sides includes hyperkaliemia, worsening renal function and/or gynecomastia. Eplerenone have however, significantly lower endocrine side effects, including gynecomastia and breast tenderness.
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