This clinical pathway recommends the following steps:
CLINICAL RECOGNITION OF TRICUSPID REGURGITATION: TR is independently associated with excess morbidity and mortality. Although mild-to-moderate TR is usually well tolerated, increasing severity may lead to dependent edema, systemic venous congestion, or symptoms of low cardiac output in advanced stages. These patients are more often older women and frequently have a higher burden of atrial fibrillation (AF). Physical examination typically shows elevated jugular venous pressure with a systolic cv wave and rapid y descent, as well as hepatomegaly, ascites, edema, and sarcopenia.
DEFINING ETIOLOGY AND MECHANISM: from an etiologic perspective, TR may be primary — rheumatic, carcinoid, or traumatic — or secondary. Secondary TR may in turn be atrial, usually in patients with AF; ventricular, related to valvular heart disease or pulmonary hypertension; or related to cardiac implantable electronic device leads, either causative or incidental. Ventricular TR carries a worse prognosis and requires closer follow-up. From a mechanistic standpoint, the Carpentier classification remains in use.
DEFINING SEVERITY:
Echocardiography: the valve must be described structurally, including leaflet characteristics, the regurgitant jet, color Doppler density, vena contracta diameter, and PISA radius. However, EROA may underestimate TR severity in up to 50% of patients because of the morphology of the regurgitant jet. Reversal of hepatic venous flow is considered a specific sign of TR. In addition to the traditional mild, moderate, and severe grades, the categories massive and torrential are now recognized because they carry a less favorable prognosis. TEE is used to assess leaflet anatomy, and high-quality imaging is required for transcatheter edge-to-edge repair. Approximately 1 in 2 patients have a 3-leaflet valve, whereas 1 in 3 have 4 leaflets, with a double posterior leaflet.
CT and CMR: CMR thresholds for severity have been extrapolated from mitral regurgitation, with a regurgitant fraction >48% considered severe, whereas a regurgitant volume ≥45 mL/beat predicts poor 1-year prognosis. CT is useful for planning interventional procedures.
DEFINING ADDITIONAL KEY FEATURES: echocardiography should include measurement of diameters and functional parameters such as TAPSE, FAC, S′ velocity, longitudinal strain, free wall strain, and 3D EF. The best parameter for estimating RV function is 3D EF, with a lower limit of 46% in women and 44% in men. Pulmonary pressures should be estimated and, in cases of uncertainty, measured invasively, together with PA-RV coupling using TAPSE/systolic PA pressure or the newer 3D echocardiographic measure of RV SV/RV end-systolic volume. An RV end-diastolic volume index <164 cc/m2 by CMR predicts volume recovery after tricuspid intervention.
CONSIDERING THE NATURAL HISTORY OF TR: TR clearly confers higher morbidity and mortality in patients with chronic heart failure (HF), with risk increasing according to TR severity. Estimated prevalences are 21% in HFpEF, 18% in HF with mildly reduced EF, and 20% in HFrEF. In severe isolated TR, estimated mortality is approximately 24% at 2 years, twice that expected in the healthy population, with 50% of deaths being cardiac in origin. In secondary TR, the phenotype associated with chronic kidney disease has the worst prognosis, with estimated 5-year mortality of 83%. Regarding TR subtype, atrial TR appears to be associated with lower mortality than ventricular TR. The TRIO-RV score estimates 1- and 3-year mortality using clinical and laboratory variables, although it is a single-center score and requires external validation.
CONSIDERING THE TYPE OF TREATMENT REQUIRED: no medical therapy currently modifies the natural history of the disease, although TR severity may be reduced through appropriate treatment of left-sided valvular heart disease or AF.
DIURETICS: loop diuretics are first-line therapy, but their efficacy is reduced in patients with renal impairment. In these cases, or in patients with diuretic resistance, treatment may be changed to a loop diuretic with higher oral bioavailability, such as bumetanide, switched to intravenous diuretic therapy, or combined with an additional diuretic to achieve sequential nephron blockade using thiazides, acetazolamide, or an SGLT2 inhibitor.
GUIDELINE-DIRECTED MEDICAL THERAPY: left-sided valvular heart disease should be treated surgically when indicated, together with management of comorbidities. In HFrEF, beta-blockers, ARNI, MRA, and SGLT2 inhibitors should be added. In HF with mildly reduced or preserved EF, SGLT2 inhibitors, GLP-1 receptor agonists in patients with obesity, or nonsteroidal MRAs are recommended, although their use has not been specifically studied for reducing TR. Cardiac resynchronization therapy has shown a 41% reduction in TR severity in patients with previous moderate-to-severe TR, whereas in patients scheduled for TAVI, TR grade decreased by up to 76%. Among patients undergoing mitral valve intervention, TR severity decreases in 30%-40% of cases. In right-sided HF, volume management is essential; however, in the presence of RV dysfunction, intervention on the tricuspid valve is not recommended.
In patients with pulmonary hypertension (PH), several agents are available for group 1 and group 4 PH, including phosphodiesterase type 5 inhibitors, endothelin receptor antagonists, prostacyclin agonists, guanosine monophosphate inducers, and even calcium channel blockers. In patients with AF, maintenance of sinus rhythm, including after pulmonary vein ablation, is associated with less TR and smaller right atrial size. In patients with device leads, lead dwell time is associated with a higher incidence of tricuspid injury after extraction, with conflicting evidence regarding whether lead extraction improves TR severity, given the progressive injury related to scarring and fibrosis after implantation. After transcatheter tricuspid valve procedures, potential complications such as lead dislodgement or lead failure must be considered; therefore, these decisions should always be made by an MDT.
The timing of referral in patients with chronic HF and associated TR may be difficult to determine. Algorithms such as the well-known I NEED HELP mnemonic, which includes variables such as edema, can support this decision-making process.
TRICUSPID VALVE INTERVENTION
SURGICAL TREATMENT
Concomitant treatment with left-sided valvular heart disease: intervention for moderate-to-severe TR is recommended when mitral valve surgery is required and surgical risk is low or moderate. This indication extends to patients with moderate TR and signs of right-sided HF, or patients with mild TR but annular dilation, defined as annulus >40 mm or 21 mm/m2, with repair preferred over replacement. Adding TR repair only increases postoperative morbidity and the incidence of permanent pacemaker implantation in approximately 15% of patients. If TR is left untreated, it may progress in 1 in 4 patients, with worse survival in this subgroup.
Treatment of isolated TR: the indication is often established late. Surgery is recommended in patients with severe TR and signs of right-sided HF, progressive RV dysfunction, or worsening renal or hepatic function, whereas it is contraindicated in patients with PH or advanced RV dysfunction. Current early mortality is 5.6%. A predictive model for 30-day in-hospital mortality includes both clinical and laboratory variables, with in-hospital mortality exceeding 60% in patients with high scores. Prehabilitation with positive inotropes and intravenous diuretics is currently advised, although surgery for isolated TR has so far shown benefit only in quality-of-life improvement and reduction in hospitalizations.
TRANSCATHETER TRICUSPID VALVE TREATMENT: 4 types are currently available. In 2024, the FDA approved 2 devices for patients with severe TR and persistent symptoms despite medical therapy, with the aim of improving quality of life: TriClip and EVOQUE.
Valve repair: several options are available, with edge-to-edge repair based on the Alfieri surgical technique using the TriClip system (Abbott) being the most widely used. Technical challenges include gaps >2 cm, markedly dilated annuli, the presence of 4 leaflets, and the need for good echocardiographic imaging to guide the procedure. Central and anterolateral gaps, and gaps <1 cm, predict procedural success. The PASCAL system (Edwards Lifesciences), with a mechanism similar to TriClip, is currently under investigation and is approved only in Europe.
Annuloplasty: Cardioband is the only device approved in Europe. It anchors a neoannulus using screws to reduce annular size and is the technique most similar to current surgical approaches, although it requires longer procedural times than other techniques.
Orthotopic transcatheter valve replacement: the EVOQUE valve (Edwards Lifesciences) is the only system approved in the United States. The TRISCEND registry included 176 patients, with 1-month and 1-year mortality of 1.7% and 9.4%, respectively, and pacemaker implantation in 13%, similar to open surgical data. The main limitations, apart from the need for permanent pacing, include the risk of device thrombosis and implantation in patients with device leads.
Heterotopic caval valve implantation: bicaval implantation is mainly used in patients with disproportionately large tricuspid annuli or RV dysfunction, with stent thrombosis being one of its major challenges.
Device selection should be agreed according to patient profile. In general, patients with good echocardiographic windows may undergo edge-to-edge repair. In patients with renal impairment, valve replacement may not be an option because CT-based preprocedural planning is required. In the presence of device leads, more than 3 leaflets, or large jets, decision-making should be individualized.
After implantation, there is an increase in afterload with a transient decrease in RV function followed by reverse remodeling. Adequate postintervention medical management is therefore essential: spironolactone should be considered, euvolemia should be carefully maintained, and any underlying HF or AF should be properly managed, while continuing salt restriction and proposing cardiac rehabilitation programs. Attention should be paid to the possible need for permanent pacing, especially because of slow AF, complete AV block, or sinus node dysfunction, while always attempting to avoid a transvalvular access. Epicardial pacing, coronary sinus pacing, or leadless pacing may be selected.
COMMENTARY
The tricuspid valve, together with the right ventricle, has moved from being largely overlooked to becoming one of the leading protagonists in contemporary cardiology. With the major advances achieved in recent years in the treatment of other valvular diseases, similar indications have often been extrapolated to the tricuspid space, despite the fact that much remains unknown about both the medical and surgical management of tricuspid disease, particularly TR. What is clear, however, is that TR is present across a large proportion of cardiac disease, and its management should therefore be a priority for any clinician who encounters it.
Across the pathway outlined in this extensive article, I would highlight 4 key issues. First, it is necessary to identify which patients with TR require treatment; to do so, clinicians must clearly recognize its symptoms and physical findings, which may at times be strikingly florid. Second, optimal medical therapy should be established, mainly for symptom relief. Third, it must be determined whether the patient has an indication for surgery, either because of another valvular disease or because of TR itself, and what the goal of intervention is, given that survival benefit data remain conflicting. Finally, the potential benefits of transcatheter treatment should be considered. In the most recent European guidelines, which are the framework in which we should apply our knowledge, transcatheter treatment carries a Class IIa, Level A indication based on the TRILUMINATE and TRISCEND II studies, with the aim of improving quality of life and RV remodeling, but only in patients without severe RV dysfunction or precapillary PH. In any case, it should be kept in mind that device approval is not uniform between the United States and Europe, and further clinical trials are needed to determine the true benefit of this technique.
From a practical standpoint, the main challenge is no longer simply to recognize severe TR, but to avoid reaching the patient too late. The key lies in identifying progressive right-sided congestion, worsening RV function, escalating diuretic requirements, or early renal and hepatic impairment before the window for intervention has closed. In this context, the MDT becomes essential to balance medical treatment, surgical risk, transcatheter feasibility, and realistic clinical benefit for each individual patient.
REFERENCE
O’Gara PT, Lindenfeld J, Hahn RT, Joseph M, Khalique OK, Khazanie P, Kumbhani DJ, Page R II, Patton KK, Thourani VH. 10 Issues for the clinician in tricuspid regurgitation evaluation and management: 2025 ACC expert consensus decision pathway. J Am Coll Cardiol. 2026;87:447-486.
