Intervention indication – Part III

Each patient with valvular heart disease is almost a book on internal medicine, considering the several associated comorbidities that they may present. Therefore, there is no general basic rule to be applied in all cases.

To help this rationale, the American Heart Association’s classification by A-D stages brings some interesting points to discuss and help the reader to have a guide in the handling of cases.

The main indications are in stages C and D, because it is an important valve disease and what differentiates both stages is the presence (stage D) or not (stage C) of symptoms.

We will divide into the specific valve diseases and their etiologies to bring a summary of the intervention indication. Each valve disease will be addressed specifically and in greater detail in specific posts.

Primary tricuspid valve disease

Stage D patients have a clear indication for intervention and the most common one here is repair with a rigid annulus deployment.

Stage C patients follow the same line of reasoning that has been exposed so far for primary etiology, but have a greater tendency to intervene given the excellent surgical results obtained.

Secondary tricuspid valve disease

Here we find a great controversy among specialists in valvopathies. There are those who argue that the conduct should be identical to functional mitral regurgitation and an approach only without cases that are refractory to clinical treatment and even so, with low levels of evidence of long-term benefits. And there are those who seek a more interventionist posture, since the evolution to systolic regurgitation of the right ventricle can greatly reduce the individual’s quality of life.

The isolated approach of tricuspid regurgitation, to date, with which we have tools for intervention, both conventional and percutaneous, has not shown a benefit in survival in this group of patients. Thus, the indication occurs only in cases of another associated valve disease that has an indication, such as something that will be addressed on the left side of the heart.

Patients with significant mitral stenosis with indication for conventional intervention have an express indication for a concomitant approach to functional tricuspid regurgitation through repair with a rigid ring implant. Apart from situations like this, there is no basis in the current literature.

Suggested literature:

1 – Braunwald, Eugene. Cardiovascular medicine treaty. 10th ed. São Paulo: roca, 2017. v.1 and v.2.