Tricuspid Regurgitation — Management Guideline
Source: 2025 ESC/EACTS Guidelines for the management of valvular heart disease, European Heart Journal
Guideline: Strong
Guideline: Conditional
Guideline: Not recommended
ClinicoQ pathway suggestion (not from the cited guideline)
Diagnosis
Diagnostic criteria
Tricuspid regurgitation is primary (valve disease) or secondary (atrial or ventricular functional, most often from left-sided heart disease). Echocardiography must do more than label it severe: the guideline expects reproducible quantification of RV size, RV function, pulmonary pressure, and right atrial and annular dilatation, because RV dysfunction and pre-capillary pulmonary hypertension determine whether intervention will help.
⚠ Alarm features (investigate before diagnosing)
- Right heart failure: congestion, ascites, or peripheral oedema despite diuretics
- RV dilatation or declining RV function
- Progressive annular dilatation
- Lead-related tricuspid regurgitation in a patient with a pacemaker or defibrillator lead
Initial workup
| Test | When to order |
|---|---|
| Transthoracic echocardiography with RV assessment | Severity, mechanism (primary vs atrial or ventricular secondary), tricuspid annulus diameter, RV size and function, and pulmonary pressure. |
| Multimodality imaging (CMR, CT) and invasive haemodynamics | When RV function or pulmonary hypertension is unclear, because severe RV dysfunction or pre-capillary pulmonary hypertension changes eligibility for intervention. |
| Comprehensive Heart Team evaluation | Mandatory before any surgical or transcatheter tricuspid intervention. |
Decision Points
❓ Does the patient need surgery on a left-sided valve?
Treatment
Severe or moderate tricuspid regurgitation with left-sided valve surgery
1
Concomitant tricuspid valve surgery for severe tricuspid regurgitation
Strong (Guideline recommendation) — Class I, level B; repair is the preferred method
- Dose
- —
- Duration
- At the index operation
- Evidence level
- High
- Avoid if
- Prohibitive surgical risk
2
Concomitant tricuspid valve surgery for moderate tricuspid regurgitation
Guideline recommendation (Class IIa, level B) — should be considered
- Dose
- —
- Duration
- At the index operation
- Evidence level
- Moderate
- Avoid if
- —
3
Concomitant tricuspid repair for mild secondary regurgitation with an enlarged annulus
Guideline recommendation (Class IIb, level B) — may be considered
- Dose
- Annulus 40 mm or above, or above 21 mm/m2
- Duration
- At the index operation
- Evidence level
- Moderate
- Avoid if
- —
Isolated severe tricuspid regurgitation (no left-sided surgery needed)
1
Medical therapy: diuretics, rhythm control, and treatment of left-heart disease
General clinical knowledge — background therapy before and alongside any intervention
- Dose
- Intensive diuretic therapy for congestion; rate or rhythm control in atrial fibrillation; address the underlying left-sided disease (general clinical knowledge, not a specific guideline recommendation)
- Duration
- Ongoing
- Evidence level
- Moderate
- Avoid if
- —
- If no response ClinicoQ pathway
- If symptoms persist, refer to the Heart Team
2
Isolated tricuspid valve surgery
Guideline recommendation — recommended in operable symptomatic patients with severe primary regurgitation (Class I, level C); should be considered in symptomatic secondary regurgitation or in asymptomatic patients with RV dilatation or declining RV function
- Dose
- —
- Duration
- Elective
- Evidence level
- Moderate
- Avoid if
- Severe LV or RV dysfunction or pre-capillary pulmonary hypertension; prohibitive surgical risk
- If no response
- Consider transcatheter intervention if the patient is at high surgical risk
3
Transcatheter tricuspid intervention (for example tricuspid edge-to-edge repair)
Guideline recommendation (Class IIa, level A) — should be considered in high-risk patients with symptomatic severe regurgitation despite optimal medical therapy, to improve symptoms and RV remodelling
- Dose
- —
- Duration
- Procedure, at a centre with experience in the tricuspid valve
- Evidence level
- High
- Avoid if
- Severe RV dysfunction or pre-capillary pulmonary hypertension
⚠️ This is an educational summary of current international clinical practice guidelines and does not replace individualized clinical judgment. Final treatment decisions remain the responsibility of the treating physician.