The ACC has released a new Expert Consensus Decision Pathway (ECDP) addressing "10 issues for the clinician in tricuspid regurgitation (TR) evaluation and management." Published in JACC, the ECDP focuses specifically on patients with secondary TR in the chronic setting and is intended to serve as a bridge to a future update of ACC/AHA valvular heart disease guideline.

"The availability of transcatheter interventions to treat severe TR has energized the cardiovascular community to improve evaluation and management strategies targeted at this valve lesion," write Patrick T. O'Gara, MD, MACC, Writing Committee chair, JoAnn Lindenfeld, MD, FACC, Writing Committee vice chair, et al. "This ECDP is intended to enable the clinician to assimilate the most important developments in this dynamically evolving field to improve the care of patients with severe TR ... and is focused on the most common clinical areas encountered in practice from evaluation to treatment."

The ECDP provides a pathway for TR evaluation and management based on five steps: identify, define, assess, treat and follow-up. An informed shared decision-making process involving a multidisciplinary team is incorporated throughout. Pathway highlights include recommendations for early screening for TR, along with use of transesophageal echocardiography (TTE) as the preferred imaging modality for defining the etiology, mechanism and severity of TR. TTE, cardiac CT and CMR, along with selective use of cardiac catheterization, can be used to augment characterization of TR severity.

Use of guideline-directed medical therapy and intervention is recommended where indicated to manage left-sided heart disease. The Writing Committee also suggests that patients with moderate or greater TR, especially those with progressing heart failure symptoms and/or escalated diuretic therapy, should be considered for referral to an advanced heart disease specialist.

In addition, "an informed shared decision-making process, incorporating individual patient values and preferences, as well as consensus multidisciplinary team recommendations, are essential for patient management," write the Committee members.