Tricuspid Regurgitation

Definition

Tricuspid regurgitation (TR) is retrograde systolic flow from the RV into the RA due to structural abnormality of the tricuspid valve (primary TR) or functional changes from RV/RA dilatation and leaflet tethering (secondary TR). sources/TV-Mx-AHA-2024 high

Epidemiology

• Significant TR (≥moderate) affects 0.55% of the population (4% in those ≥75 years); independently associated with death and HF; 15-year observed survival 10.2%; isolated TR carries 12.1% annual mortality sources/TV-Mx-AHA-2024 high
• All-cause mortality by TR severity: even mild TR = ~30% increased long-term all-cause mortality; moderate–severe TR = HR 2.0–3.2 vs no/mild TR sources/tr-nejm-2023 very high
• 1-year mortality with medical management of severe TR: 36–42% in two major studies sources/tr-nejm-2023 very high
• Comparative disease burden: all-cause mortality HR for TR (2.74) is higher than for aortic valve disease (1.62) or mitral valve disease (1.25) — UK Biobank data sources/tr-nejm-2023 very high
• Rapid progression predictors: pacemaker/defibrillator leads, mild TR at baseline, annular dilatation, any valve surgery without concomitant TV surgery sources/tr-nejm-2023 very high

Pathophysiology

• Annular susceptibility: Only 40% annular dilatation may result in clinically significant TR (vs 75% in mitral valve studies) — the tricuspid annulus has little fibrous tissue/collagen, making it uniquely vulnerable; dilatation occurs preferentially anterolaterally (RV free wall direction, away from fibrous skeleton support from the septum) sources/tr-nejm-2023 very high
• Atrial secondary TR: AF-driven; RA and annular dilatation with preserved RV function and pulmonary pressures; no significant leaflet tethering — early intervention may prevent RV involvement sources/vhd-esc-2025 very high
• Ventricular secondary TR: LV/RV disease or post-capillary PH causing annular dilatation + leaflet tethering; RV pressure/volume overload accelerates annular remodelling; worse prognosis than atrial secondary TR sources/vhd-esc-2025 very high
• Advanced stages may blur the atrial vs ventricular distinction — early characterisation is critical sources/vhd-esc-2025 very high
• Sex differences: Females have a larger tricuspid annulus (even after body/heart weight correction); males have more myocardial cells and elastic fibres histologically sources/tr-nejm-2023 very high

Aetiology

• Primary TR (8–10%): Infective endocarditis, rheumatic disease, carcinoid, congenital (Ebstein's), trauma, iatrogenic (endomyocardial biopsy), CIED-related (lead-induced valve damage)
• Secondary TR (>90%):
  • Atrial secondary TR: AF-driven; RA and annular dilatation without RV pressure overload or leaflet tethering
  • Ventricular secondary TR: LV/RV disease or post-capillary PH causing annular dilatation + leaflet tethering; worse prognosis

TV Anatomy

• Classic anatomy: 3 leaflets — anterior (largest, most mobile), posterior (often multi-scalloped), septal (smallest, arises from IVS with multiple chordal attachments)
• Leaflet nomenclature (Type I–IV): Type I = 3 leaflets; Type II = 2; Type IIIA/B/C = 4; Type IV = >4 leaflets; ~39% of cases have ~4 functional leaflets predominantly comprising 2 posterior leaflets sources/TV-Mx-AHA-2024 high
• Annulus: nonplanar, elliptical; posteroseptal = most ventricular; anteroseptal = most atrial
• Adjacent critical structures: RCA (AV groove), AV node + His bundle (adjacent to septal leaflet/anteroseptal commissure), coronary sinus (posteroseptal RA), aortic root (non-coronary sinus near anteroseptal commissure) sources/TV-Mx-AHA-2024 high
• RCA proximity: Narrows to <3 mm inferiorly along the posterior annulus — highest risk of injury with annular anchoring devices sources/tr-nejm-2023 very high
• AV node/His bundle: Cross the septal leaflet 3–5 mm from the anteroseptal commissure — risk of complete heart block with septal interventions sources/tr-nejm-2023 very high

Diagnosis / Evaluation

TR Severity Grading (5-Grade Scale, ASE/AHA 2017)

• VC measured as average of 2 orthogonal views; 3D VCA preferred for complex jets
• Dense early-peaking triangular CW Doppler envelope = rapid RV-RA pressure equalisation → severe TR
• Hepatic vein flow reversal = moderate or severe TR
• PA pressures may be underestimated in severe TR due to V-wave cutoff sign on CW Doppler
• Assess when euvolaemic; repeat imaging after volume optimisation if overloaded at baseline sources/TV-Mx-AHA-2024 high

Multimodality Imaging

• TTE: Multiple views (parasternal RV inflow, short-axis, apical 4-chamber anterior + posterior focus); TR easily underestimated if full large TA not imaged; 3D TTE and biplane improve annular anatomy and leaflet characterisation sources/TV-Mx-AHA-2024 high
• TEE: Primary modality for intraprocedural guidance; transgastric short-axis en face view visualises all leaflets simultaneously; 3D TEE with MPR for en face RA/RV perspective; limited by probe-to-TV distance, variable anatomy, device shadowing sources/TV-Mx-AHA-2024 high
• ICE: Alternative to TEE when window suboptimal; 2D ICE (higher frame rate) essential in ~70% TEER cases; 4D ICE for annuloplasty (superior lateral annulus visualisation); added cost and learning curve sources/TV-Mx-AHA-2024 high
• CT: Annular measurements, RCA proximity, subvalvular anatomy for TTVR planning; TR quantification (RV-LV stroke volume difference); delivery catheter planning (femoral/iliac/IVC diameter, IVC-TA trajectory) sources/TV-Mx-AHA-2024 high
• CMR: Accurate RV volumes/RVEF and TR quantification (phase-contrast); baseline RVEF important pre-TTVR (afterload mismatch risk) sources/TV-Mx-AHA-2024 high
• Integrative echo grading based on qualitative + quantitative parameters; assessment in euvolaemic state
• RHC mandatory before any intervention: RA pressure, end-diastolic RVDP, mean PAP, PAWP, PVR — essential to exclude masked pre-capillary PH (poor outcome predictor)

RV Function Assessment

• TAPSE, TDI S', FAC, RV free-wall longitudinal strain (speckle tracking), 3D RVEF
• RV-PA coupling (TAPSE/sPAP): High baseline ratio independently associated with lower all-cause mortality post-TV intervention; use caution as PA pressures may be underestimated in severe TR sources/TV-Mx-AHA-2024 high

Risk Stratification

• TRI-SCORE and STS isolated TV risk calculator for peri-operative risk stratification sources/vhd-esc-2025 very high

Management

Medical Therapy

• Treat underlying cause: GDMT for HF, pulmonary vasodilators for PH, rhythm control for AF
• Primary TR: Diuretics Class 2a; treat primary cause
• Secondary TR (HFrEF): RAAS/ARNI + BB + MRA + SGLT2i Class I — reduces secondary TR through structural reverse remodeling
• Secondary TR (HFpEF): Diuretics Class I; SGLT2i Class 2a; ARNI/MRA/ARB Class 2b
• Rhythm control for AF: variable effect on TR depending on underlying cause, atrial dilation, and other conditions — evidence not consistent
• Diuretics in stepwise fashion (loop diuretics → aldosterone antagonists → SGLT2i)
• No medical therapy can directly reverse TR — only improves it indirectly through volume and structural remodeling; should not delay expert centre evaluation when TR is significant sources/TV-Mx-AHA-2024 high sources/vhd-esc-2025 very high

Surgical Management

Outcomes Data

• Overall in-hospital mortality: 8–10% (comorbidities: RV/renal/liver dysfunction)
• Without major risk factors: 1.7% national mortality; single-centre results better (volume-outcome relationship)
• Isolated TV surgery: ~20% of all TV surgeries (~5,000 over 10 years in US); patients significantly younger than transcatheter therapy recipients
• Repair (ring annuloplasty — gold standard): Undersized ring effective for dilated annulus; DeVega suture-based largely abandoned for poor durability
• Replacement: Mechanical vs bioprosthetic — similar 5-year outcomes; bioprosthesis durability approaching 15 years; mechanical may show earlier adverse events sources/TV-Mx-AHA-2024 high

Indications — Isolated TR

• Class I C: TV surgery in symptomatic patients with severe primary TR without severe RV dysfunction or severe PH sources/vhd-esc-2025 very high
• Class IIa C: TV surgery in asymptomatic severe primary TR with RV dilatation/function deterioration (without severe RV/LV dysfunction or severe PH)
• Class IIa B: TV surgery in symptomatic severe secondary TR or with RV dilatation/dysfunction (without severe LV/RV dysfunction or PH)
• Class IIa B-NR (AHA 2020): Symptomatic severe isolated secondary TR from annular dilation (no PH/LV dysfunction) poorly responsive to medical therapy → isolated TV surgery beneficial sources/VHD-AHA-2020 very high
• Class IIb C-LD (AHA 2020): Asymptomatic severe primary TR with progressive RV dilation or dysfunction → TV surgery may be considered sources/VHD-AHA-2020 very high

Indications — Concomitant TR with Left-Sided Valve Surgery (ESC 2025)

• Class I B (new): TV surgery recommended for severe primary or secondary TR at time of left-sided surgery
• Class IIa B (new): TV repair should be considered for moderate primary or secondary TR to prevent progression and RV remodelling (supported by 2 recent RCTs)
• Class IIb B (new): TV repair may be considered for mild secondary TR with annular dilatation (≥40 mm or >21 mm/m²) — weighed against increased pacemaker risk (up to 14% after annuloplasty) sources/vhd-esc-2025 very high
• Class I B-NR (AHA 2020): Severe TR undergoing left-sided valve surgery → concomitant TV surgery
• Class IIa B-NR (AHA 2020): Progressive TR (Stage B) undergoing left-sided surgery + annular dilation >4.0 cm OR prior right-HF → TV surgery beneficial sources/VHD-AHA-2020 very high

Transcatheter Treatment

TEER (Edge-to-Edge Repair)

• TRILUMINATE Pivotal (RCT — TriClip vs medical therapy; N=350; intermediate/high surgical risk): 1:1; 65 centres USA/Canada/Europe; mean age 78; 90% AF; 70.7% massive/torrential TR; 93.9% functional TR; RHC mandated at enrollment sources/tvteer-triluminate-nejm-2023 very high
  • Win ratio 1.48 (95% CI 1.06–2.13; P=0.02) — hierarchical composite of death/TV surgery, HF hospitalisation, KCCQ ≥15-point improvement
  • No significant difference in mortality (KM 9.4% vs 10.6%) or HF hospitalisation rate (0.21 vs 0.17/pt-yr — control marginally lower)
  • KCCQ ≥15-pt improvement: 49.7% TEER vs 26.4% control — primary driver of win ratio
  • Mean KCCQ change: +12.3 pts TEER vs +0.6 pts control (P<0.001); without imputation: +15.2 vs +4.8 pts
  • TR ≤moderate at 30 days: 87.0%; at 1 year: 88.1% (TEER) vs 5.7% control; NYHA class I/II at 1 year: 83.9% vs 59.5%
  • 6MWD change: −8.1 m vs −25.2 m (P=0.25, NS); without imputation: +11.5 vs −8.7 m
  • QoL–TR reduction correlation: TR ≤moderate → mean KCCQ +15.6; TR severe+ → +3.8; ≥2 grade reduction → +18 pts; no change → +2 pts
  • Safety: 98.8% device implant success; 98.3% MAE-free at 30 days; PPM 2.9% in both groups (no increase with TEER); BARC ≥3a bleeding 5.2%; no device embolization or thrombosis; single-leaflet attachment 7.0% (no associated MAEs)
  • TriClip G4 FDA-approved for symptomatic severe TR sources/TV-Mx-AHA-2024 high
• TEER efficacy benchmarks: Reduces TR to ≤moderate in 80–85% of patients; to ≤mild in only 30–50% — limited by jet location, coaptation gap, lead impingement, leaflet complexity sources/tr-nejm-2023 very high
• PASCAL Precision: CLASP TR US EFS (n=34): 85% ≥1 grade TR reduction; 52% TR ≤moderate at 30 days; pivotal RCT ongoing sources/TV-Mx-AHA-2024 high

Transcatheter Annuloplasty

• Cardioband (CE mark 2018): EFS (n=37): 83% success; 73% had ≥2 grade TR reduction at 1 year; 73% TR ≤moderate sources/TV-Mx-AHA-2024 high

Transcatheter TV Replacement (TTVR)

• EVOQUE TRISCEND EFS: n=56; 98% procedural success; 98% TR mild or less at 30 days; 11% pacemaker; 3.6% 30-day mortality; FDA-approved based on TRISCEND II 6-month data sources/TV-Mx-AHA-2024 high
• EVOQUE TRISCEND II pivotal RCT (NEJM 2025): N=400; 2:1 randomization; 45 centres USA + Germany; mean age 79.2 yrs; 75.5% women; 94.9% AF; mean STS 9.7%; >50% massive/torrential TR at baseline sources/ttvr-triscendii-nejm-2025 very high
  • Win ratio 2.02 (95% CI 1.56–2.62; P<0.001) favouring TTVR at 1 year
  • Primary benefit QoL-driven: KCCQ-OS ≥10 pts 66.4% vs 36.5%; NYHA ≥1 class 78.9% vs 24.0%; 6MWD ≥30 m 47.6% vs 31.8%
  • TR ≤mild in 95.2% TTVR patients vs 2.3% controls at 1 year
  • RV reverse remodeling: RV EDD −5.8 mm; IVC −4.8 mm; TAPSE −4.2 mm (expected — afterload increase); RV FAC −9.3%
  • All-cause death: 12.6% vs 15.2% (not powered); HF hospitalisation: 20.9% vs 26.1% (not powered)
  • Severe bleeding: 15.4% vs 5.3% (P=0.003) — predominantly periprocedural (10.4% vs 1.5% at 30 days); 31–365 day rates similar (5.3% vs 4.7%)
  • New PPM: 17.4% vs 2.3% (P<0.001); 27.8% in TTVR patients without prior pacemaker; rates comparable to surgical TV repair/replacement
  • No patients required RVAD implantation or heart transplantation
• TTVR efficacy benchmarks: Reduces TR to ≤mild in >90% of patients; however, sudden TR elimination may increase RV afterload and unmask mechanical dysfunction sources/tr-nejm-2023 very high

Heterotopic Replacement

• TricValve and TRICENTO systems; for high-risk patients with severe TR-related venous congestion without native TA intervention; early EFS data only sources/TV-Mx-AHA-2024 high

ESC 2025 Recommendations

• Class IIa A (upgraded from IIb C): Transcatheter TV treatment should be considered to improve QoL and promote RV remodelling in high-risk patients with symptomatic severe TR despite optimal medical therapy, without severe RV dysfunction or pre-capillary PH sources/vhd-esc-2025 very high
• Evidence base: TRILUMINATE Pivotal, Tri.Fr (TEER + GDMT vs GDMT alone), TRISCEND II
• Transcatheter TV replacement reduces TR more completely than repair but has less favourable safety profile
• All transcatheter TV procedures should be performed at experienced Heart Valve Centres with dedicated TV expertise
• Careful anatomical eligibility assessment required: jet location, coaptation gap, leaflet tethering, CIED lead position sources/vhd-esc-2025 very high
• Note: ACC/AHA 2020 does not include transcatheter TV treatment (no RCT evidence at time of publication); TRILUMINATE and TRISCEND II published after 2020 → ESC 2025 upgraded transcatheter TV to Class IIa A sources/VHD-AHA-2020 very high

Therapy Selection and Lifetime Management

• No guidelines exist to determine repair vs replacement for individual patients — field still evolving
• TEER may be difficult with large coaptation gaps (large annuli from AF/RV failure); requires high-quality imaging
• Concern about complete sudden TR elimination in severe PH → acute RV failure and haemodynamic instability
• Sequence matters: annuloplasty first may preserve future TEER/TTVR options; some TEER devices may preclude subsequent devices
• CIED lead position must inform device choice and future pacing options
• Liver function assessment mandatory before intervention (TR-related hepatic congestion vs intrinsic liver disease affects long-term outcomes)
• Volume optimisation ("prehab" IV diuresis) before imaging/procedure for accurate anatomical assessment sources/TV-Mx-AHA-2024 high

CIED-Related TR

• Distinguish CIED-related TR (lead causing valve damage) from CIED-associated TR (incidental)
• Up to 60% of worsened TR after CIED implantation was of another origin (AF, prior cardiac surgery) — not device-related; careful attribution is essential sources/tr-nejm-2023 very high
• Lead repositioning or extraction may improve TR in selected patients; lead removal performed in a timely fashion may prevent severe RV dilatation and dysfunction
• However, removal worsens TR in ~10% and injures the valve in ~3% sources/tr-nejm-2023 very high
• Transcatheter interventions may need to account for CIED leads in device sizing and implantation planning

Special Populations

Carcinoid Heart Disease

• Occurs in 20–50% of patients with carcinoid syndrome — due to fibrosis/endocardial thickening from chronic high serotonin exposure sources/tr-nejm-2023 very high
• Short-term mortality with valve replacement may be lower with earlier intervention and careful preoperative planning sources/tr-nejm-2023 very high

Endocarditis

• AngioVac-assisted vegetation debulking (meta-analysis, n=301): vegetation size reduced >50% in 89.2% of patients sources/tr-nejm-2023 very high
• No significant difference in short-term outcomes between valvectomy and surgical valve replacement for infective tricuspid-valve endocarditis; repair associated with lower risk of permanent pacemaker sources/tr-nejm-2023 very high

Follow-up

• Moderate or severe TR: clinical and echo follow-up at least every 6 months
• After transcatheter intervention: close follow-up given high residual TR rates and ongoing RV remodelling process

Contradictions / Open Questions

• No mortality benefit demonstrated in any RCT for transcatheter TR treatment — TRILUMINATE Pivotal (TEER, WR 1.48) and TRISCEND II (TTVR, WR 2.02) both QoL-driven; all-cause death 12.6% vs 15.2% (TRISCEND II, NS, not powered); whether TR treatment modifies mortality remains unknown sources/TV-Mx-AHA-2024 high sources/ttvr-triscendii-nejm-2025 very high
• TTVR vs TEER efficacy–safety tradeoff: TRISCEND II achieves TR ≤mild in 95.2% (vs TEER 30–50%); win ratio 2.02 (vs TRILUMINATE 1.48); but severe bleeding 15.4% vs 5.3% and new PPM 27.8% in naive patients (vs ~11% TEER) — no head-to-head RCT; optimal patient selection not defined sources/ttvr-triscendii-nejm-2025 very high vs sources/TV-Mx-AHA-2024 high
• HF hospitalization paradox in both RCTs: In TRILUMINATE Pivotal, control had a marginally lower HF hospitalisation rate (0.17 vs 0.21/pt-yr); in TRISCEND II, TTVR had fewer wins on HF hospitalization (9.7% vs 10.0%). Despite TR elimination and QoL improvement, neither TEER nor TTVR reduced HF hospitalization — possibly Hawthorne effect, rigorous patient selection, atrial secondary TR predominance (lower baseline HF burden), or insufficient follow-up; 5-year data needed sources/tvteer-triluminate-nejm-2023 very high sources/ttvr-triscendii-nejm-2025 very high
• Echo core laboratory blinding gap (TRILUMINATE): TR severity graded by core lab aware of group assignments — potential for differential TR grading bias favouring TEER; echocardiographic outcomes should be interpreted with this caveat sources/tvteer-triluminate-nejm-2023 very high
• Rhythm control and TR: Some patients experience TR reduction after successful rhythm control; evidence is not consistent — effect depends on underlying cause, atrial dilation, and other conditions sources/TV-Mx-AHA-2024 high
• Concomitant TV repair for mild TR with annular dilatation: benefit may be offset by higher pacemaker implantation rate (up to 14% after annuloplasty), which is itself associated with worse long-term HF outcomes sources/vhd-esc-2025 very high
• Optimal timing for isolated TV surgery remains debated — patients often referred too late when RV dysfunction is advanced and surgery carries prohibitive risk
• AHA 2024 vs ESC 2025 transcatheter TV: AHA 2024 Scientific Statement describes TEER and EVOQUE as FDA-approved without formal class recommendations; ESC 2025 provides Class IIa A recommendation — both incorporate TRILUMINATE Pivotal and TRISCEND II data sources/TV-Mx-AHA-2024 high vs sources/vhd-esc-2025 very high
• Long-term device durability: No transcatheter TV device has long-term durability data; TEER may limit future TTVR options depending on device deployed; annuloplasty may best preserve future options sources/TV-Mx-AHA-2024 high

Connections

• Related to concepts/Valvular-Heart-Disease
• Related to concepts/Secondary-Mitral-Regurgitation
• Related to concepts/Primary-Mitral-Regurgitation
• Related to concepts/Mitral-Stenosis
• Related to concepts/RV-PA-Coupling — TAPSE/sPAP predicts post-intervention mortality in TR
• Related to concepts/Structural-Valve-Deterioration — future durability concern for transcatheter TV devices
• Related to concepts/Periprocedural-CIED-Management — CIED lead position informs transcatheter TV device choice
• Related to entities/Atrial-Fibrillation
• Related to entities/Heart-Failure
• Related to concepts/pulmonary-hypertension

Sources

• sources/tr-nejm-2023
• sources/TV-Mx-AHA-2024
• sources/VHD-AHA-2020
• sources/vhd-esc-2025
• sources/ttvr-triscendii-nejm-2025
• sources/tvteer-triluminate-nejm-2023