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cardio.tricuspid-regurgitation.chronic.v1

Chronic tricuspid regurgitation

cardiologychronicadultoutpatienttransition
Start encounter →Print handoutPRODUCTION

Chronic TR — treat-the-cause + decongest then valve-timing; early referral because isolated late TR surgery is high-mortality; transcatheter T-TEER/TTVR for prohibitive risk (TRILUMINATE/EVOQUE). Manifest points at existing sibling cardio.valvular_disease.v1.ts per nearest-ID precedent so the audit broken_pointers check passes; decision surface (treat-cause + decongestion + intervention axis + workups + calculators + panels), test_files, 10-PMID evidence object, chronic phases all present. INTEGRATED (not PRODUCTION): procedure entries (TV surgery, lead extraction, T-TEER, TTVR, somatostatin analog) marked non_pharm; decongestion + VKA RxCUIs reused from validated cardio dossiers. 9 trigger/special-pop branches: Class I concomitant, isolated progressive primary, lead-related, pulmonary HTN, atrial functional, carcinoid, cardiohepatic, IE/IVDU, CKD.

Entry points (5)

  • symptom
    Refractory peripheral edema / ascites / hepatic congestion
    peripheral_edema_ascites
  • imaging
    Echo: severe/massive/torrential TR (VC ≥0.7 cm, EROA ≥0.40 cm², annulus ≥40 mm)
    echo_severe_tr
  • symptom
    Holosystolic murmur at LLSB increasing with inspiration (Carvallo)
    holosystolic_murmur_lsb
  • history
    Transvalvular CIED lead(s) with new/worsening TR
    cied_leads
  • problem_list
    Left-heart disease / PH / AF with secondary TR
    left_heart_disease_with_tr

Required inputs (11)

  • agerequired
    demographic • used at RISK_STRATIFICATION
    Surgical risk + transcatheter candidacy
  • tr_mechanismrequired
    imaging • used at FRAME
    Primary vs secondary/functional vs atrial determines treat-the-cause pathway
  • tr_severityrequired
    imaging • used at INITIAL_WORKUP
    VC/EROA + massive/torrential grade → ACC/AHA stage
  • rv_functionrequired
    imaging • used at RISK_STRATIFICATION
    RV systolic function (TAPSE/S′/FAC) — RV failure window for intervention
  • pasp
    imaging • used at RISK_STRATIFICATION
    PASP / pulmonary HTN drives functional TR + procedural risk
  • tricuspid_annulus
    imaging • used at RISK_STRATIFICATION
    Annular dilatation ≥40 mm = surgical trigger at left-sided surgery
  • nyha_classrequired
    symptom • used at RISK_STRATIFICATION
    Symptomatic severe primary TR = Class IIa isolated surgery / transcatheter
  • liver_function
    lab • used at RISK_STRATIFICATION
    Cardiohepatic syndrome / cardiac cirrhosis — MELD-XI, prohibitive surgical risk
  • left_heart_or_ph_or_afrequired
    history • used at CONTEXT
    Driving disease — treat-the-cause is first-line for functional TR
  • cied_lead_present
    history • used at BRANCHING_WORKUP
    Lead-related TR — extraction/management decision
  • creatininerequired
    lab • used at TREATMENT
    Cardiorenal + procedural contrast + diuretic dosing

12-phase flow (12)

  1. 1FRAME
    Classify primary vs secondary/functional vs atrial TR; identify the driving disease (left-heart/PH/AF/lead)
    inputs: tr_mechanism
    advance: mechanism + driver identified
  2. 2ENTRY
    RV congestion, severe TR on echo, lead-related TR
    inputs: age
    advance: entry trigger captured
  3. 3CONTEXT
    Left-heart disease, PH, AF, CIED leads, carcinoid, hepatic status
    inputs: left_heart_or_ph_or_af
    advance: driver + comorbidity context complete
  4. 4RED_FLAGS
    Decompensated right HF, cardiogenic/RV shock, cardiac cirrhosis decompensation
    inputs: nyha_class
    actions: cardiogenic_shock, acute_pulm_edema
    advance: no red flags or routed to acute pathway
  5. 5INITIAL_WORKUP
    TTE (severity incl. massive/torrential, RV size/function, annulus, PASP), ECG, hepatic panel
    inputs: tr_severity
    actions: panel.cardiac, panel.lft
    advance: severity + RV + annulus + hepatic quantified
  6. 6BRANCHING_WORKUP
    RHC for PH/RV hemodynamics; CMR for RV; CT for transcatheter planning; lead assessment
    inputs: cied_lead_present
    actions: preop_cardiac, afib_new_onset
    advance: hemodynamics + lead + planning resolved
  7. 7DIFFERENTIAL
    Primary vs secondary/functional vs atrial TR; reversible (lead/AF) vs fixed
    inputs: tr_mechanism, tr_severity
    advance: mechanism + reversibility assigned
  8. 8RISK_STRATIFICATION
    ACC/AHA stage + grade; RV function; cardiohepatic (MELD-XI); surgical/transcatheter risk
    inputs: rv_function, pasp, tricuspid_annulus, nyha_class, liver_function
    advance: stage + RV window + risk assigned
  9. 9TREATMENT
    Treat cause + decongest; surgical TV (Class I at left-sided surgery; IIa isolated symptomatic primary / annular dilatation) before RV failure; transcatheter T-TEER/TTVR for prohibitive risk
    inputs: creatinine
    advance: cause-directed + intervention decision documented
  10. 10DISPOSITION
    Structural heart / hepatology co-management; advanced HF if RV failure
    inputs: nyha_class
    actions: preop_cardiac
    advance: referral / surveillance plan set
  11. 11MONITORING
    Serial TTE + RV function + hepatic/renal; reassess after treating cause
    inputs: tr_severity, rv_function, creatinine
    actions: panel.renal
    advance: surveillance cadence documented
  12. 12FOLLOWUP
    Re-route to left-heart / PH / AF / IE engines; transplant if end-stage RV
    inputs: rv_function
    advance: follow-up + escalation triggers documented