Tricuspid stenosis medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Vamsikrishna Gunnam M.B.B.S [2] ;Mohammed Salih, M.D. ;Rim Halaby, M.D. [3]

Overview

Medical therapy with diuretics and sodium restriction is the mainstay of treatment among patients with tricuspid stenosis complicated by systemic and pulmonary congestion. Patients with tricuspid stenosis should receive medical therapy for left heart failure, and/or pulmonary hypertension in case they are present.

Medical Therapy

• Pharmacologic medical therapies for tricuspid stenosis include diuretic therapy.
• Loop diuretics may be helpful in relieving some of the symptoms which include:
  • Hepatic congestion
  • Decreases the preload
  • Systemic venous hypertension
  • Lower extremity edema
• Due to the risk of worsening low-flow syndrome diuretics may be used with caution in patients with tricuspid stenosis.
• Medical interventions were also indicated with patients who are having atrial fibrillation in the settings of tricuspid stenosis which include the following:

2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

Class IIa

1.   In patients with signs and symptoms of right-sided HF attributable to severe TR (Stages C and D), diuretics can be useful. (Level of Evidence: C-EO) " 2.   In patients with signs and symptoms of right-sided HF attributable to severe secondary TR (Stages C and D), therapies to treat the primary cause of HF (eg, pulmonary vasodilators to reduce elevated pulmonary artery pressures, GDMT for HF with reduced LVEF, or rhythm control of AF) can be useful. (Level of Evidence: C-EO)

Pharmacological Cardioversion

Class I

"1. Flecainide, dofetilide, propafenone, and intravenous ibutilide are useful for pharmacological cardioversion of AF or atrial flutter provided contraindications to the selected drug are absent. (Level of Evidence: A) "

Class III: Harm

"1. Dofetilide therapy should not be initiated out of hospital owing to the risk of excessive QT prolongation that can cause torsades de pointes. (Level of Evidence: B) "

Class IIa

"1. Administration of oral amiodarone is a reasonable option for pharmacological cardioversion of AF. (Level of Evidence: A) "

"2. Propafenone or flecainide (“pill-in-the-pocket”) in addition to a beta blocker or nondihydropyridine calcium channel antagonist is reasonable to terminate AF outside the hospital once this treatment has been observed to be safe in a monitored setting for selected patients. (Level of Evidence: B) "

• Medical interventions were also indicated with patients who are having systemic rheumatic diseases and endocarditis as the cause of tricuspid stenosis.
• Treating the patients who are having systemic lupus erythematosus (SLE) and antiphospholipid antibodies (APLA) may reduce the coating over the infected valves and chordae and in turn reduces the stenosis and regurgitation.