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Treatment options

Medical therapy for tricuspid regurgitation (TR) has limited clinical benefit and patients are often referred when it is too late for surgery.1,2 However, recent cohorts have demonstrated improved outcomes with early referral and more effective techniques.2

Professor Michael Boehm

There is such a close interaction between medical treatment, intervention, and also comorbidities, that this makes clear that it is an interdisciplinary problem.*

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Professor Michael Boehm 

Saarland University Hospital, Homburg, Germany 

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

Based on the 2025 European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS) Guidelines for the management of valvular heart disease:2

  • Patients should be treated according to the assumed cause of their TR, including optimal heart failure (HF) treatment, pulmonary vasodilators for pulmonary hypertension (PH) and rhythm control for atrial fibrillation  
    • However, none of these measures should delay evaluation of an intervention at an expert centre 
  • Patients with TR should be carefully evaluated for TR aetiology, stage of the disease, patient operative risk and likelihood of recovery by a multidisciplinary Heart Team prior to intervention 

Surgical intervention has high in-hospital mortality when patients present late, but recent studies have demonstrated improved outcomes when patients are referred earlier and more effective treatment are used.3,4

Medical therapy

There is currently no Class I recommended medical therapy for symptomatic, severe TR in the 2025 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.

Surgical intervention

The 2025 ESC/EACTS Guidelines recommendations for surgery in patients with TR and left-sided valvular heart disease requiring surgery:2

Class I/B circle

Concomitant tricuspid valve surgery* is recommended for: 

  • Patients with severe primary or secondary TR
Class IIa/B

Concomitant tricuspid valve repair should be considered for: 

  • Patients with moderate primary or secondary TR, to avoid progression of TR and RV remodelling
Class IIb/B

Concomitant tricuspid valve repair may be considered for: 

  • Selected patients with mild secondary TR and tricuspid annulus dilatation (≥40 mm or >21 mm/m2), to avoid progression of TR and RV remodelling

*Valve repair whenever possible.
RV: right ventricle/ventricular; TR: tricuspid regurgitation. 

The 2025 ESC/EACTS Guidelines recommendations for surgery in patients with severe TR without left-sided valvular heart disease requiring surgery:2

Circle I/C

Tricuspid valve surgery* is recommended for:

  • Symptomatic patients with severe primary TR without severe RV dysfunction or severe PH
Class IIa/C

Tricuspid valve surgery* should be considered for:

  • Asymptomatic patients with severe primary TR who have RV dilatation/RV function deterioration, but without severe LV/RV dysfunction or severe PH 
Class IIa/B

Tricuspid valve surgery* should be considered for:

  • Patients with severe secondary TR who are symptomatic or have RV dilatation/RV function deterioration, but without severe LV/RV dysfunction or PH 

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

Isolated tricuspid valve surgery is considered to be generally high risk.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

Transcatheter tricuspid valve intervention (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.

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

The 2025 ESC/EACTS Guidelines recommendations for TTVI in patients with severe TR without left-sided valvular heart disease requiring surgery:2

Circle IIa/A

To improve quality of life and RV remodelling, TTVI should be considered for:

  • High-risk patients with symptomatic, severe TR despite optimal medical therapy, in the absence of severe RV dysfunction or pre-capillary PH

PH: pulmonary hypertension; RV: right ventricle/ventricular; TR: tricuspid regurgitation; TTVI: transcatheter tricuspid valve intervention.

Book

2025 ESC/EACTS Guidelines for the management of valvular heart disease

The latest guidelines introduce pivotal changes in the management of MR.
Explore the key changes

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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