cardio.tricuspid-regurgitation.chronic.v1PRODUCTION

cardio.tricuspid-regurgitation.chronic.v1

Chronic tricuspid regurgitation

cardiologychronicadult

Hard-required inputs

0 / 7

Care setting:

Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Classify primary vs secondary/functional vs atrial TR; identify the driving disease (left-heart/PH/AF/lead)

Inputs

Actions

Advance rule

Set

Advance when

mechanism + driver identified

Patient inputs (11)

left_heart_or_ph_or_af*history • CONTEXT

not present

Driving disease — treat-the-cause is first-line for functional TR

tr_mechanism*imaging • FRAME

not present

Primary vs secondary/functional vs atrial determines treat-the-cause pathway

tr_severity*imaging • INITIAL_WORKUP

not present

VC/EROA + massive/torrential grade → ACC/AHA stage

age*demographic • RISK_STRATIFICATION

Surgical risk + transcatheter candidacy

rv_function*imaging • RISK_STRATIFICATION

not present

RV systolic function (TAPSE/S′/FAC) — RV failure window for intervention

nyha_class*symptom • RISK_STRATIFICATION

Symptomatic severe primary TR = Class IIa isolated surgery / transcatheter

creatinine*lab • TREATMENT

Cardiorenal + procedural contrast + diuretic dosing

cied_lead_presenthistory • BRANCHING_WORKUP

not present

Lead-related TR — extraction/management decision

paspimaging • RISK_STRATIFICATION

not present

PASP / pulmonary HTN drives functional TR + procedural risk

tricuspid_annulusimaging • RISK_STRATIFICATION

not present

Annular dilatation ≥40 mm = surgical trigger at left-sided surgery

liver_functionlab • RISK_STRATIFICATION

Cardiohepatic syndrome / cardiac cirrhosis — MELD-XI, prohibitive surgical risk

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (9)

9 need judgement

informationalsevereclass_I_tv_surgery_concomitant
Severe TR in a patient undergoing left-sided valve surgery — Class I concomitant TV repair — 2020 ACC/AHA VHD
Trigger could not be auto-evaluated — needs clinician judgement.
informationalsevereisolated_primary_tr_progressive
Isolated severe symptomatic primary TR with progressive RV dilatation/dysfunction — Class IIa surgery; refer before RV failure — 2020 ACC/AHA VHD
Trigger could not be auto-evaluated — needs clinician judgement.
informationalseverecarcinoid_heart_disease_branch
Carcinoid heart disease — somatostatin analog control + TV (and pulmonary valve) surgery; 5-HIAA + hormone load management — 2020 ACC/AHA VHD
Trigger could not be auto-evaluated — needs clinician judgement.
informationalseverecardiohepatic_syndrome_branch
Cardiac cirrhosis / congestive hepatopathy (rising bilirubin, MELD-XI) — hepatology co-management; prohibitive surgical risk if advanced — 2020 ACC/AHA VHD
Trigger could not be auto-evaluated — needs clinician judgement.
informationalsevereie_ivdu_branch
Tricuspid IE (IVDU) with leaflet destruction — route to IE engine for antibiotic + surgical timing — 2020 ACC/AHA VHD
Trigger could not be auto-evaluated — needs clinician judgement.
informationalmoderatelead_related_tr_branch
CIED transvalvular lead causing/worsening TR — lead extraction or management as part of strategy — 2020 ACC/AHA VHD
Trigger could not be auto-evaluated — needs clinician judgement.
informationalmoderatepulmonary_htn_branch
Functional TR driven by pulmonary HTN — RHC + Group-specific PH therapy; PH severity drives procedural risk — ESC/ERS PH 2022
Trigger could not be auto-evaluated — needs clinician judgement.
informationalmoderateatrial_functional_tr_branch
Atrial functional TR (AF + annular dilatation, normal RV/PA pressure) — rhythm control + treat AF — ESC 2024 AF
Trigger could not be auto-evaluated — needs clinician judgement.
informationalmoderateckd_special_pop
Cardiorenal — diuretic resistance management, contrast minimisation for procedural CT — KDIGO 2024
Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

Run this disease's risk and dosing calculators inline.

TREATMENTrequiredDrives dose adjustment

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Recommended regimen

Chronic TR — treat-the-cause + decongest then intervention timing (2020 ACC/AHA VHD)

axis: chronic_tr_treat_cause_then_intervenestep 1 - Step 1 — Treat the driving disease

Selected step "Step 1 — Treat the driving disease" — Functional TR from left-heart disease / PH / AF

outpatient playbook — drug actions (2)

1. treat driving disease (HF GDMT / PH therapy / AF rhythm)
per driver engine • varied • varied
trigger: Functional TR (2020 ACC/AHA VHD)
Treat-the-cause is first-line for functional TR
2. loop diuretic ± spironolactone
furosemide 40 mg ± spironolactone 25–50 mg • PO • daily
trigger: RV congestion/ascites (2020 ACC/AHA VHD)
Decongestion bridge

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Refractory peripheral edema / ascites / hepatic congestion; Echo: severe/massive/torrential TR (VC ≥0.7 cm, EROA ≥0.40 cm², annulus ≥40 mm); Holosystolic murmur at LLSB increasing with inspiration (Carvallo).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Chronic tricuspid regurgitation** (cardio.tricuspid-regurgitation.chronic.v1).
Phenotype framing: Primary vs secondary/functional vs atrial TR; reversible (lead/AF) vs fixed
Scope: Classify primary vs secondary/functional vs atrial TR; identify the driving disease (left-heart/PH/AF/lead)

No severity triggers fired against current inputs.

Plan

Regimen axis: **Chronic TR — treat-the-cause + decongest then intervention timing (2020 ACC/AHA VHD)** — step "Step 1 — Treat the driving disease".

Setting playbook (outpatient) — Treat the driver, decongest, and refer for TV intervention before RV failure / cardiac cirrhosis (2020 ACC/AHA VHD)
1. treat driving disease (HF GDMT / PH therapy / AF rhythm) per driver engine varied varied — Functional TR (2020 ACC/AHA VHD) (Treat-the-cause is first-line for functional TR)
2. loop diuretic ± spironolactone furosemide 40 mg ± spironolactone 25–50 mg PO daily — RV congestion/ascites (2020 ACC/AHA VHD) (Decongestion bridge)

Non-pharmacologic actions:
- Refer to structural heart team early — isolated late TR surgery has high mortality — 2020 ACC/AHA VHD
- Hepatology co-management for cardiac cirrhosis — 2020 ACC/AHA VHD
- Lead extraction/management for lead-related TR — 2020 ACC/AHA VHD

AVOID / contraindication checks:
- Refer isolated severe TR before RV failure late surgery high mortality — 2020 ACC/AHA VHD
- Treat driving left heart or PH or AF before labeling TR refractory — 2020 ACC/AHA VHD
- Mechanical tricuspid prosthesis highly thrombogenic prefer bioprosthesis — 2020 ACC/AHA VHD
- Transcatheter TR only if prohibitive surgical risk and suitable anatomy — TRILUMINATE
- DOAC contraindicated rheumatic valve AF use VKA — 2020 ACC/AHA VHD

Monitoring

Regimen monitoring:
- TTE RV function and TR grade after treating cause — 2020 ACC/AHA VHD
- hepatic and renal panel for cardiohepatic cardiorenal — 2020 ACC/AHA VHD
- serial TAPSE FAC for RV failure window — 2020 ACC/AHA VHD
- post-intervention TTE baseline then annually — 2020 ACC/AHA VHD
- INR if VKA — 2020 ACC/AHA VHD

Setting (outpatient) monitoring:
- Serial TTE RV + TR grade; hepatic/renal panels — 2020 ACC/AHA VHD
- Congestion + weight review each visit — 2020 ACC/AHA VHD

Follow-up plan: Re-route to left-heart / PH / AF / IE engines; transplant if end-stage RV
- Close-out criterion: follow-up + escalation triggers documented

Monitoring phase: Serial TTE + RV function + hepatic/renal; reassess after treating cause

Disposition

Current setting: outpatient — Treat the driver, decongest, and refer for TV intervention before RV failure / cardiac cirrhosis (2020 ACC/AHA VHD)

Disposition criteria:
- TR improves after treating cause → continue driver-engine surveillance
- Severe symptomatic primary / progressive → surgical TV referral
- Prohibitive surgical risk → transcatheter T-TEER/TTVR evaluation

Escalation triggers (move to higher acuity):
- Progressive RV dysfunction or cardiac cirrhosis → expedite TV intervention before inoperable — 2020 ACC/AHA VHD
- Severe TR at planned left-sided valve surgery → concomitant TV surgery (Class I) — 2020 ACC/AHA VHD
- Decompensated right HF/shock → ED + right-HF/shock pathway — 2022 ACC/AHA HF

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [SEVERE] Severe TR in a patient undergoing left-sided valve surgery — Class I concomitant TV repair — 2020 ACC/AHA VHD
- [SEVERE] Isolated severe symptomatic primary TR with progressive RV dilatation/dysfunction — Class IIa surgery; refer before RV failure — 2020 ACC/AHA VHD
- [SEVERE] Carcinoid heart disease — somatostatin analog control + TV (and pulmonary valve) surgery; 5-HIAA + hormone load management — 2020 ACC/AHA VHD

Citations

- 2020 ACC/AHA VHD Guideline + 2021 ESC/EACTS VHD Guideline [PMID:33332149](https://pubmed.ncbi.nlm.nih.gov/33332149/)
- Cited evidence (PMID 34453165) [PMID:34453165](https://pubmed.ncbi.nlm.nih.gov/34453165/)
- Cited evidence (PMID 36876753) [PMID:36876753](https://pubmed.ncbi.nlm.nih.gov/36876753/)
- Cited evidence (PMID 30877080) [PMID:30877080](https://pubmed.ncbi.nlm.nih.gov/30877080/)
- Cited evidence (PMID 35379504) [PMID:35379504](https://pubmed.ncbi.nlm.nih.gov/35379504/)

Last reconciled with current guidelines: 2026-05-16.

References

2020 ACC/AHA VHD Guideline + 2021 ESC/EACTS VHD Guideline — PMID:33332149
Cited evidence (PMID 34453165) — PMID:34453165
Cited evidence (PMID 36876753) — PMID:36876753
Cited evidence (PMID 30877080) — PMID:30877080
Cited evidence (PMID 35379504) — PMID:35379504