Tricuspid regurgitation is a public health crisis☆
Introduction
Tricuspid regurgitation (TR) is a valvular condition which is frequent and has long been perceived as being well-known and well-understood.1 Therefore, the claim that TR represents a public health crisis is not simple to comprehend. Unfortunately, the concept of public health crisis is poorly defined and may be misunderstood for a public health emergency. In our opinion, the first element is the frequency of the condition; indeed, a rare condition may be very serious and warranting treatment but cannot amount to a public health crisis. The second element besides the frequency of the condition is its impact on outcome. A frequent condition that is benign cannot become a public health crisis. The third element to consider is the limited treatment received by the carriers of the condition, whether the treatment is often ineffective or whether an effective treatment is not administered.
TR is defined by the regurgitation of blood from the right ventricle (RV) to the right atrium, which is normally prevented by the coaptation of the tricuspid leaflets during systole.1,2 Because presence of at least trivial TR is discovered in the vast majority of subjects, even with completely normal hearts, it is indispensable to consider trivial TR as physiologic in most subjects and thus inconsequential.1,2 Hence, the grading of TR by Doppler-echocardiography is crucial.3 While the clinical significance of mild TR is most often considered benign, the TR that deserves the most attention is severe TR, and most recent data suggests that even moderate TR is also consequential and warrants our attention.4 Therefore, the question to be examined is whether moderate or severe TR among our national community represents a public health crisis by fulfilling all three criteria of frequency, poor outcome and insufficient/ineffective treatment. Unfortunately, in view of its previous reputation of a benign condition,5 the background knowledge regarding TR has remained quite scarce and because TR is also heterogeneous6 the literature may be quite confusing and uncertain.
Section snippets
Epidemiology of TR: is TR a frequent condition?
The epidemiology of TR is poorly known. Similar to other valve diseases the clinical examination is generally unrevealing7,8 and many cases of confirmed TR are undetected clinically. This lack of sensitivity of clinical examination for TR makes Doppler-echocardiography the main tool for detecting TR in the population.1 Color flow imaging is highly sensitive for TR, which has been shown to be quite frequent in the normal population. The American Society of Echocardiography has provided
Outcome of TR: is TR a serious condition?
This question is the most difficult to answer as historical data provided blanket answers that were contradictory. Indeed, on one hand TR was recommended as benign enough to require only conservative management5 and it was even estimated that complete surgical removal of the tricuspid valve was associated with excellent tolerance and outcome.15 On the other hand TR diagnosed by echocardiography, irrespective of its cause, was found overall to severely impact outcome.16 These contradictory
Treatment of TR: is there an unmet need for treatment?
The only currently approved treatment for TR is cardiac surgery with tricuspid valve repair or replacement.31 The only class I indication for TR surgery is for severe TR in the context of mitral surgery. To consider whether the need for treatment is met or not, one must consider effectiveness of surgical treatment and the consistency and frequency of treatment application.
TR public health crisis: the way forward
With TR now proven to bear the hallmarks of a public health crisis as a condition that is frequent in the population, affecting millions of mostly older patients, complicated by severe HF and excess mortality and treated only in a minimal fraction of those affected, it is abundantly clear that a plan of action is necessary. The way forward involves:
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Paying more attention to diagnosing moderate and severe TR, which ideally encompasses increased use of quantitative Doppler-echocardiographic
Statement of conflict of interest
None of the authors have any conflicts of interests with regard to this publication.
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Statement of conflict of interest: see page 451.