Clinical Quick Reference — Evaluation and Management
Tricuspid regurgitation affects 4% of individuals aged ≥75 years. TR is usually secondary to RV/RA enlargement rather than primary valve pathology. Clinical recognition is the first step in the pathway—findings may include elevated JVP, hepatosplenomegaly, peripheral edema, and elevated RV pressures.
Three primary etiologic categories: (1) primary TR, (2) secondary TR (atrial or ventricular), and (3) CIED-related TR. Each has distinct pathophysiology and management implications.
| Classification | Subtype | Primary Etiologies |
|---|---|---|
| Primary TR | — | Degenerative, Endocarditis, Trauma, Eisstein anomaly, Carcinoid, Rheumatic, Congenital |
| Secondary TR | Ventricular (V-STR) | RV dilatation, LV dysfunction, Pulmonary hypertension, Chronic lung/PE disease, IVC shunt |
| Atrial (A-STR) | Atrial arrhythmias, HFpEF | |
| CIED-related | Causative | Lead-TV leaflet interaction |
| Incidental | CIED present but not direct cause |
TTE is the imaging modality of first choice. Guidelines recommend assessing TR severity with a combination of structural, qualitative, semi-quantitative, and quantitative measures.
| Severity | VC Width (mm) | PISA EROA (mm²) | RVol (mL) | RF (%) |
|---|---|---|---|---|
| Mild | <3 | <20 | <30 | <15 |
| Moderate | 3–6.9 | 20–39 | 30–44 | 15–49 |
| Severe | ≥7 | ≥40 | ≥45 | ≥50 |
RV function assessment is critical to guide intervention timing and predict outcomes. RV dysfunction portends worse prognosis.
| Parameter | Mild Dysfx | Moderate Dysfx | Severe Dysfx |
|---|---|---|---|
| TAPSE (mm) | 14–17 | 10–13 | <10 |
| RV S' (cm/s) | 9–11 | 6–8 | <6 |
| RV GLS (%) | 18–21 | 14–17 | <14 |
| RV FAC (%) | 34–47 | 30–33 | <30 |
| 3D RV EF (%) | 45–50 | 35–45 | <35 |
TR is independently associated with excess mortality. Two risk models predict outcomes: TRIO score (1–3 year) and TRIO-RV score (3-year). Use MAGGIC HF Survival Calculator for HF cohorts.
No guideline Class I medical therapies exist specifically for TR. Optimization of left-sided HF and comorbidities is foundational.
AF is present in 18–45% of moderate-to-severe TR and is a risk factor for TR progression. Restoring sinus rhythm has been associated with TA remodeling reduction and TR improvement.
Anticoagulation: Use CHA₂DS₂-VASc for stroke risk and HAS-BLED for bleeding risk assessment.
Referral to advanced HF/valvular specialist should be considered for severe isolated TR with symptoms, moderate TR with progressive RV dysfunction, or CIED-related causative TR.
| Letter | Definition | Description |
|---|---|---|
| I | Inotropes | Previous/current inotropic support requirement |
| N | NYHA | Persistent Class III–IV despite GDMT |
| E | End-organ dysfx | Worsening renal or hepatic dysfunction |
| D | Defibrillator shocks | Recurrent appropriate ICD shocks |
| H | Hospitalizations | ≥1 HF admission in 12 months |
| E | Edema/escalating diuretics | Persistent fluid overload |
| L | Low BP | SBP <90 mm Hg |
| P | Prognostic meds | Inability to uptitrate GDMT |
Optimal timing for isolated TV surgery is undefined. Surgery is often performed concomitant with left-sided valve disease. Use EuroSCORE II for surgical risk assessment.
| Risk Factor | Points |
|---|---|
| Age ≥70 years | 1 |
| NYHA Class III–IV | 1 |
| Right-sided HF signs | 2 |
| Daily furosemide ≥125 mg | 2 |
| GFR <30 mL/min | 2 |
| Elevated bilirubin | 2 |
| LVEF <60% | 1 |
| Moderate/severe RV dysfx | 1 |
Four main platforms available: (1) T-TEER (MitraClip/TriClip), (2) annuloplasty devices, (3) TTVR, (4) heterotopic CAVI. Choice depends on anatomy, function, and patient candidacy.
| Approach | T-TEER | TTVR |
|---|---|---|
| Mechanism | Leaflet approximation (repair) | Valve replacement (prosthetic) |
| Advantages | • Wide anatomy applicability • Less invasive • Native valve preserved • Lower thromboembolism | • Most effective TR reduction • Suitable for severe pathology • CIED-TR capable • High-risk surgery alternative |
| Limitations | • Requires excellent imaging • Less effective with severe tethering • Modest TR reduction in some | • Limited device sizes • RV dysfunction concerns • Leaflet thrombosis risk • Lifelong anticoagulation |
TRILUMINATE (T-TEER): 350 patients; KCCQ improved 12.3 vs 0.6 in control (P < 0.001). 87% achieved ≥30% TR reduction.
TRISCEND II (TTVR): Multi-center RCT comparing device therapy vs OMT alone; favorable QoL trends, FDA approval in 2024 for symptomatic severe TR on OMT.
Predicts in-hospital mortality after TTVI based on AF, GFR <30, elevated GGT/bilirubin, RV HF signs, LVEF <50%. Cut-off 2.5 differentiates high vs low risk.
Continue GDMT post-intervention; monitor volume status closely. Euvolemia assessment guides safe discharge.
| Parameter | Euvolemic | Mild Congestion | Moderate | Severe |
|---|---|---|---|---|
| Orthopnea | None | Mild | Present | >2 pillows |
| JVP | <8 cm | <10 or HJR+ | 8–10 | >10 |
| Hepatomegaly | Absent | Liver edge | Moderate | Massive/tender |
| Edema | None | +1 | +2 | +3/+4 |
| 6MWT | >400 m | 300–400 | 200–300 | <100 m |
| BNP/NT-proBNP | <100/<400 | 100–299/400–1500 | 300–500/1500–3000 | >500/>3000 |
Follow-up: TTE at 6–12 weeks post-TTVI, repeat annually. Continue GDMT; manage AF; monitor for device-specific complications.
Surgical risk prediction for cardiac surgery including TV repair
Glomerular filtration rate for renal function and diuretic dosing
Creatinine clearance for drug dosing in CKD
1–3 year survival prediction in heart failure
Hepatic dysfunction in cardiorenal syndrome
RV function and PA systolic pressure assessment
Pulmonary vascular resistance at catheterization
Stroke risk in AF patients requiring anticoagulation
Bleeding risk in AF on anticoagulation and diuretics
Body surface area normalization for valve metrics