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Treatment options

Tricuspid regurgitation (TR) treatment options have been limited with mixed outcomes.1,2

Based on the 2021 European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS) Guidelines for the management of valvular hear disease:2

  • Medical therapy focuses on volume control with diuretics
  • Although data are limited, rhythm control may help to decrease TR and contain annular dilatation in patients with chronic atrial fibrillation (AF)
  • Limited data suggest that rhythm control strategies in chronic AF may reduce TR and limit annular dilatation
  • No Class I recommended medical therapy for symptomatic, severe TR
  • Transcatheter tricuspid valve intervention (TTVI) may be considered for inoperable patients with severe, symptomatic secondary TR 

Surgical intervention has high in-hospital mortality when patients present late, and unclear benefits compared with medical treatment.3,4

Medical therapy

There is currently no Class I recommended medical therapy for symptomatic, severe TR in the 2021 ESC/EACTS Guidelines. Medical treatment for TR is primarily focused on volume management with diuretics.2,5

Dr Ali Vazir

Medical therapy alone shows little benefit in terms of long-term prognosis for patients with significant TR.*

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Dr Ali Vazir, consultant in cardiology and critical care,
Royal Brompton Hospital, London, United Kingdom

*Expert opinions, advice and all other information expressed represent contributors' views and not necessarily those of Edwards Lifesciences.

Dr Ali Vazir

Surgical intervention

The 2021 ESC/EACTS Guidelines recommendations for surgery on primary and secondary TR:2

2021 ESC/EACTS recommendations on primary TR ClassLevel
Surgery is recommended in patients with severe primary TR undergoing left-sided valve surgery.IC
Surgery is recommended in symptomatic patients with isolated severe primary TR without severe right ventricular (RV) dysfunction.IC
Surgery should be considered in patients with moderate primary TR undergoing left-sided valve surgery.IIaC
Surgery should be considered in asymptomatic or mildly symptomatic patients with isolated severe primary TR and RV dilatation who are appropriate for surgery.IIaC
2021 ESC/EACTS recommendations on secondary TRClassLevel
Surgery is recommended in patients with severe secondary TR undergoing left-sided valve surgery.IB
Surgery should be considered in patients with mild or moderate secondary TR with a dilated annulus (≥40 mm or >21 mm/m2 by 2D echocardiography) undergoing left-sided valve surgery.IIaB
Surgery should be considered in patients with severe secondary TR (with or without previous left-sided surgery) who are symptomatic or have RV dilatation, in the absence of severe RV or left ventricle (LV) dysfunction and severe pulmonary vascular disease/hypertension.*IIaB

*In patients with previous surgery, recurrent left-sided valve dysfunction needs to be excluded.

Surgical repair procedures for TR6

There are three distinct surgical techniques employed to address issues with the tricuspid valve.6

The De Vega annuloplasty involves placing a double row of sutures along the annulus of the anterior and posterior leaflets, effectively gathering the valve annulus to reduce its size. Bicuspidisation is a procedure where a suture is strategically placed along the annulus of the posterior leaflet, specifically reducing its size and creating a bicuspid valve configuration. In contrast, ring annuloplasty utilises a rigid or semirigid tricuspid valve ring of an appropriate size, which is then implanted at the annulus of the tricuspid valve to provide structural support and improve valve function.6

Late surgical correction of isolated secondary TR carries uncertain benefit over medical management and poses significant periprocedural risks.2

Fewer than 1% of patients image

<1% of patients with moderate or greater TR are treated with surgery annually7

9% mortality

8.8% in-hospital mortality risk for isolated tricuspid valve surgery8

6% predicted risk

5.6% overall predicted risk of operative mortality for isolated tricuspid valve surgery9

Transcatheter techniques are now available to treat severe or greater TR

TTVI is an emerging treatment option for patients with severe or greater TR at high surgical risk. It is less invasive than surgery and aims to reduce symptoms and improve quality of life.10-13


Prof. Dr med. Jörg Hausleiter

Compared with surgery, TTVI may be a low-risk procedure we can offer to patients*

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Prof. Dr med. Jörg Hausleiter, interventional cardiologist, University of Ludwig-Maximilian, Munich, Germany

*Expert opinions, advice and all other information expressed represent contributors' views and not necessarily those of Edwards Lifesciences.

Prof. Dr med. Jörg Hausleiter

Let’s turn the page on the undertreatment of TR14

TTVI for the treatment of patients with severe, symptomatic TR has gained increasing attention in recent years.12-14

Learn more
grey heart

References

  1. Sala A, Hahn RT, Kodali SK, et al. Tricuspid valve regurgitation: Current understanding and novel treatment options. J Soc Cardiovasc Angiogr Interv. 2023;2(5):101041. doi:10.1016/j.jscai.2023.101041.
  2. Vahanian A, Beyersdorf F, Praz F, et al. 2021 ESC/EACTS Guidelines for the management of valvular heart disease: Developed by the Task Force for the management of valvular heart disease of the European Society of Cardiology(ESC) and the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J. 2022;43(7):561–632. doi:10.1093/eurheartj/ehab395.
  3. Dreyfus J, Flagiello M, Bazire B, et al. Isolated tricuspid valve surgery: impact of aetiology and clinical presentation on outcomes. Eur Heart J. 2020;41(45):4304–4317. doi:10.1093/eurheartj/ehaa643.
  4. Al-Hijji M, Fender EA, El Sabbagh A, et al. Current treatment strategies for tricuspid regurgitation. Curr Cardiol Rep. 2017;19(11):106. doi:10.1007/s11886-017-0920-4.
  5. Dernektsi C, Tanaka T, Vogelhuber J, et al. Tricuspid regurgitation – Part 2: Treatment options. Accessed 19 March 2025, https://www.escardio.org/Councils/Council-for-Cardiology-Practice-(CCP)/Cardiopractice/tricuspid-regurgitation-part-2-treatment-options.
  6. Rodés-Cabau J, Taramasso M, O'Gara P. Diagnosis and treatment of tricuspid valve disease:current and future perspectives. Lancet 2016;388:2431–42.doi:10.1016/S0140-6736(16)00740-6.
  7. Fender EA, Zack CJ, Nishimura RA. Isolated tricuspid regurgitation: Outcomes and therapeutic interventions. Heart. 2018;104(10):798–806. doi:10.1136/heartjnl-2017-311586.
  8. Zack CJ, Fender EA, Chandrashekar P, et al. National trends and outcomes in  isolated tricuspid valve surgery. J Am Coll Cardiol. 2017;70(24):2953–2960. doi:10.1016/j.jacc.2017.10.039.
  9. Thourani VH, Bonnell L, Wyler von Ballmoos MC, et al. Outcomes of isolated tricuspid valve surgery: A Society of Thoracic Surgeons analysis and risk model. Ann Thorac Surg. 2024;118(4):873–881. doi:10.1016/j.athoracsur.2024.04.014.
  10. Taramasso M. Expanding the tools for transcatheter tricuspid valve intervention: Transcatheter tricuspid valve repair. JACC Case Rep. 2020;2(8):1112–1114. doi:10.1016/j.jaccas.2020.05.056.
  11. Maisano F, Hahn R, Sorajja P, et al. Transcatheter treatment of the tricuspid valve: Current status and perspectives. Eur Heart J. 2024;45(11):876–894. doi:10.1093/eurheartj/ehae082.
  12. Ning X, Xu H, Cao J, et al. Transcatheter tricuspid valve interventions: Current devices and clinical evidence. J Cardiol. 2024;84(2):73–79. doi:10.1016/j.jjcc.2024.04.001.
  13. Abdalla H, Nkomo V, Arsanjani R, et al. Rapid development of severe mitral regurgitation following tricuspid valve intervention. Eur Heart J Cardiovasc Imaging. 2024;26(1):148–149. doi:10.1093/ehjci/jeae244.
  14. Ascione G, Del Forno B, Carino D, et al. Treatment of isolated tricuspid regurgitation in 2020: An update. Fac Rev. 2020;9:26. doi:10.12703/r/9-26.
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