Dina Al Rameni MD, Hashim Sabet MD
Hartford Hospital/UConn Health
December 31, 2024
Abbreviations and Definitions
ACC – American College of Cardiology
AHA – American Heart Association
ERO – Effective regurgitant orifice area
RA – Right atrium
RV – Right ventricle
TR – Tricuspid regurgitation
TTE – Transthoracic echocardiography
TEER – Transcatheter edge-to-edge repair
TTVR – Percutaneous transcatheter tricuspid valve replacement
Indications & Guidelines for Management by Grade/Stage of Disease
Tricuspid regurgitation (TR) occurs when the tricuspid valve fails to close properly, causing blood to flow backward from the right ventricle (RV) into the right atrium (RA) instead of moving into the pulmonary circulation. It can be classified as either primary, due to a structural valve issue (e.g., carcinoid, congenital, iatrogenic, infective endocarditis, radiation, or rheumatic), or secondary, resulting from either dilated cardiomyopathy, left-sided heart disease, pulmonary hypertension, or RV volume overload.1
Classification/Staging
TR is classified into stages based on the severity of the valve dysfunction and its impact on the heart and patient symptoms. These stages help guide management and treatment decisions. The classification typically follows guidelines from the ACC and the AHA.1
Stage A: At risk
Valve function: Normal valve function, but at risk of developing TR.
Symptoms: None.
Management: Monitoring and addressing risk factors.
Stage B: Progressive TR
Valve hemodynamics: Mild to moderate TR. Central jet <50% RA. Vena contracta width <0.7 cm. ERO <0.4 cm2. Regurgitant volume <45 mL.
Symptoms: Often asymptomatic or mild symptoms.
Management: Regular follow-up with echocardiography and managing underlying causes.
Stage C: Asymptomatic severe TR
Valve hemodynamics: Severe TR. Central jet >50% RA. Vena contracta width >0.7 cm. ERO >0.4 cm2. Regurgitant volume >45 mL. Dense continuous wave signal with triangular shape. Hepatic vein systolic flow reversal.
Symptoms: None directly attributable to the regurgitation.
Management: Close monitoring and consideration for intervention if the right ventricular function begins to decline.
Stage D: Symptomatic severe TR
Valve hemodynamics: Severe TR. Central jet >50% RA. Vena contracta width >0.7 cm. ERO >0.4 cm2. Regurgitant volume >45 mL. Dense continuous wave signal with triangular shape. Hepatic vein systolic flow reversal.
Symptoms: Symptomatic, often with signs of right heart failure (dyspnea, fatigue, peripheral edema, ascites).
Management: Surgical or transcatheter intervention is often considered, especially if symptoms worsen or right ventricular function continues to deteriorate.
TR severity is often graded on a scale from mild to severe, corresponding to the volume of blood leaking back through the tricuspid valve and the effect on the heart’s function, which can be summarized as mild (Grade 1), moderate (Grade 2), moderately severe (Grade 3), and severe (Grade 4).
Mild to moderate TR
Intervention is typically not indicated unless there is progressive right ventricular dilation or dysfunction.1
Monitoring with serial echocardiography is recommended, particularly if pulmonary hypertension or left-sided heart disease is present.1
Severe TR
Isolated severe TR with symptoms (e.g., right heart failure, ascites, peripheral edema) warrants surgical consideration.1,4
The 2020 ACC/AHA guidelines recommend tricuspid valve surgery (repair preferred over replacement) in symptomatic patients with severe primary TR, or in those undergoing left-sided valve surgery, even if TR is moderate or greater (Class I indication).1
ESC 2021 guidelines emphasize early surgical referral before irreversible right ventricular dysfunction develops (Class I–IIa recommendation depending on context).3
Secondary (functional) TR
Surgery is recommended during left-sided valve surgery (mitral or aortic) if there is severe TR or moderate TR with annular dilation (>40 mm or >21 mm/m²), even in the absence of severe symptoms.1,3,5
In isolated functional TR, surgery is reasonable (Class IIa) if the patient is symptomatic and the RV remains functional.1,3
Emerging percutaneous therapies
Transcatheter tricuspid valve intervention (TTVI) is an emerging alternative in high-risk surgical patients with symptomatic severe TR.6
Current guidelines suggest TTVI may be considered in select patients within clinical trials or registries (Class IIb indication).1
Table 1. Indications for Tricuspid Valve Intervention (2020 ACC/AHA Guidelines).
| Stage | Recommendation | Class of Recommendation | Level of Evidence |
|---|---|---|---|
| Severe primary TR with symptoms | Surgery (preferably repair) is recommended | Class I | B-NR |
| Severe TR at the time of left-sided valve surgery | Surgery on the tricuspid valve is recommended (preferably repair) | Class I | B-NR |
| Moderate functional TR with annular dilatation (>40 mm) at the time of left-sided valve surgery | Tricuspid valve repair is reasonable | Class IIa | B-NR |
| Progressive TR with right ventricular dysfunction without severe TR | Surgery may be considered during left-sided valve surgery | Class IIb | C-LD |
| Severe isolated TR without left-sided disease in high surgical risk patients | Percutaneous tricuspid intervention may be considered | Class IIb | B-NR |
Surgical repair/replacement
The tricuspid valve’s proximity to key structures such as the atrioventricular node, coronary sinus, and right coronary artery necessitates careful surgical technique. Tricuspid valve repair options include suture annuloplasty, such as De Vega’s technique (which reduces annular diameter but risks myocardial tearing), and ring annuloplasty using rigid or semi-rigid rings to reinforce annular stability. The Clover technique, adapted from the Alfieri stitch, involves approximating the leaflet centers, combined with ring annuloplasty. Additional repair strategies depend on the underlying pathology, such as leaflet prolapse, chordal rupture, or papillary muscle dysfunction.7 When repair is not feasible, as in extensive endocarditis or carcinoid disease, valve replacement is preferred.
When valve replacement is necessary in the tricuspid position, bioprosthetic and mechanical valves are feasible. The decision regarding the type of valve should be made with careful consideration of the patient’s overall health, biological age, and specific risk factors rather than adopting a one-size-fits-all approach. TVR with mechanical valves, whenever considered clinically reasonable and accepted by patients as an option, can offer a better long-term survival and lower risk of reoperation in the long run.8,9 Mechanical valves carry a higher risk of bleeding and thromboembolic events. In contrast, bioprosthetic valves demonstrate lower thrombotic risk and allow for easier future interventions, such as pacemaker or defibrillator lead placement, which are more commonly needed after right-sided valve surgery.10
Transcatheter repair/replacement
Several innovative technologies for transcatheter tricuspid valve repair are being explored, including transcatheter edge-to-edge repair (TEER), transcatheter valve replacement (TTVR), and annuloplasty devices.6 TEER is the most commonly used method, while TTVR is still under clinical evaluation. Challenges in clip deployment arise due to the proximity of the inferior vena cava, with best results seen when targeting the septal and anterior leaflets. Additionally, transcatheter annuloplasty devices are being investigated for functional TR, with the combined use of coaptation and annuloplasty devices potentially offering improved outcomes.
Ongoing Trials/Recent Publications
The TRILUMINATE Pivotal trial, sponsored by Abbott, began enrollment on August 21, 2019, and concluded on June 29, 2022, with a total of 572 participants across 68 centers in five countries. The study is ongoing, with participants being followed for five years. Initial results were presented at the ACC’s annual scientific session in March 2025, and the two-year data were published in Circulation. The study demonstrated that TEER using the TriClip significantly reduced heart failure hospitalizations by 28% compared to medical therapy alone (0.19 vs. 0.26 events per patient-year; P = 0.02). The trial’s estimated completion date is April 30, 2029.11
The 2019-06 – TRISCEND study is a multicenter, prospective single-arm study aimed at evaluating the safety and performance of the Edwards EVOQUE Tricuspid Valve Replacement System, expected to be completed by 2029.
Expert Commentary
In our experience, intervening on every tricuspid valve during mitral valve surgery is unnecessary and, at times, excessive. We typically reserve tricuspid valve repair for cases where TR has been present for more than six months. Acute TR secondary to mitral pathology often improves following mitral valve repair. The size of the RA provides important insight into the chronicity of regurgitation; significant RA enlargement or clinical signs of right heart failure, such as ascites or pleural effusions, indicate that the tricuspid disease is more chronic than acute and needs to be addressed. However, a tense small RA does not necessarily indicate the need for intervention.
We are cautious about routine tricuspid annuloplasty, as the addition of a ring carries a notable risk of requiring permanent pacemaker implantation. Dual-chamber pacing, especially if not directly pacing the left ventricle, is not ideal and can compromise cardiac output. Therefore, a strategy of blanket tricuspid ring placement is not part of our standard practice.
While De Vega annuloplasty can be effective in the acute setting, its long-term durability is limited. Additionally, devices like the TriClip do not have an equivalent surgical technique, unlike TEER in mitral disease, which is copied from the Alfieri stitch; hence, its durability remains to be seen.
Special attention is needed for the tricuspid subvalvular apparatus, as the right-sided papillary muscles are less robust and stable compared to the left side. Importantly, we do not hesitate to perform mechanical tricuspid valve replacements when indicated, and in our experience, mechanical valves on the right side do not exhibit higher thrombosis rates than expected.
Sources
- Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, et al. 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. Circulation. 2021;143(5):e72–e227. doi:10.1161/CIR.0000000000000923.
- Kim HK, Lee SP, Kim YJ, Sohn DW. Tricuspid regurgitation: clinical importance and its optimal surgical timing. J Cardiovasc Ultrasound. 2013 Mar;21(1):1-9. [] []
- Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, et al. 2021 ESC/EACTS Guidelines for the Management of Valvular Heart Disease. European Heart Journal. 2022;43(7):561–632. doi:10.1093/eurheartj/ehab395.
- Dreyfus GD, Corbi PJ, Chan KMJ, Bahrami T. Secondary tricuspid regurgitation or dilatation: Which should be the criteria for surgical repair? Annals of Thoracic Surgery. 2005;79(1):127–132. doi:10.1016/j.athoracsur.2004.06.044.
- Taramasso M, Vanermen H, Maisano F, Franzen O, Baldus S, Latib A, et al. The growing clinical importance of secondary tricuspid regurgitation. Journal of the American College of Cardiology. 2012;59(9):703–710. doi:10.1016/j.jacc.2011.08.079.
- Taramasso M, Benfari G, Hahn RT. The evolution of transcatheter tricuspid valve intervention: Present and future. European Heart Journal. 2021;42(7):636–647. doi:10.1093/eurheartj/ehaa913.
- McCarthy PM, Bhudia SK, Rajeswaran J, Hoercher KJ, Lytle BW, Cosgrove DM, et al. Tricuspid valve repair: Durable results for functional tricuspid regurgitation. Annals of Thoracic Surgery. 2004;78(1):194–202. doi:10.1016/j.athoracsur.2004.02.090.
- Sá, Michel Pompeu et al, Long-Term Outcomes of Tricuspid Valve Replacement With Mechanical Versus Tissue Valves: Meta-Analysis of Reconstructed Time-to-Event Data. American Journal of Cardiology, Volume 225, 89 – 97
- Sohn SH, Kang Y, Kim JS, Hwang HY, Kim KH, Choi JW. Early and long-term outcomes of bioprosthetic versus mechanical tricuspid valve replacement: A nationwide population-based study. J Thorac Cardiovasc Surg. 2024 Jun;167(6):2117-2128.e11. doi: 10.1016/j.jtcvs.2023.01.025. Epub 2023 Feb 4. PMID: 36894350.
- Kang et al. Fifteen-Year Outcomes After Bioprosthetic and Mechanical Tricuspid Valve Replacement. The Annals of Thoracic Surgery, Volume 110, Issue 5, 1564 – 1571
- Kar, Saibal. Two-year Outcomes of Transcatheter Tricuspid Valve Edge-to-Edge Repair for Tricuspid Regurgitation: The TRILUMINATE Pivotal Trial. Paper presented at the American College of Cardiology Annual Scientific Session, Chicago, IL, March 30, 2025.
