Tricuspid regurgitation and stenosis — practice case: atrial secondary TR to transcatheter repair

Presentation

Practice case (not a real patient). A 79-year-old woman with long-standing permanent AF has 6 months of exertional breathlessness, abdominal bloating and ankle oedema despite a loop diuretic. TTE shows severe TR with structurally normal leaflets, marked RA and annular dilatation, normal LV function and no significant left-sided valve disease.^[2][1] She has no pacemaker or ICD. Her creatinine and liver tests are mildly abnormal.^[1]

Step 1 — What kind of TR is this?

Discussion:

• Structurally normal leaflets make this secondary TR; ESC/EACTS 2025 describes an atrial phenotype, mainly due to AF, with marked RA and annular dilatation, no significant leaflet tethering and preserved RV size and function, pulmonary pressure and LV function.^[1]
• At an advanced stage the atrial and ventricular phenotypes may no longer be distinguishable, and current recommendations for intervention consider mainly primary versus secondary TR.^[1]
• ACC/AHA 2020 notes that there appears to be a subgroup of significant isolated TR attributable mainly to annular dilation, usually with AF, without pulmonary hypertension or LV systolic dysfunction; with symptoms, her severe TR is Stage D.^[2]

Step 2 — Work-up

Discussion:

• Grade TR ideally in euvolaemia with optimised pressures, integrating multiple parameters, and use CMR when accurate RV size, function and volume are needed for a decision (ESC/EACTS 2025).^[1]
• Right heart catheterisation is recommended in severe TR before surgical or interventional repair (ESC/ERS 2022, Class I, Level C); ESC/EACTS 2025 adds that pressures and vascular resistance are key to excluding masked severe pre-capillary PH.^[6][1]
• In severe TR, a multidisciplinary Heart Team evaluation of aetiology, disease stage, operative risk and likelihood of recovery is recommended before intervention (ESC/EACTS 2025, Class I, Level C). The TRI-SCORE and the STS isolated TV risk calculator take into account clinical and echo signs of RV dysfunction and secondary organ (particularly hepatic and renal) impairment; ESC/EACTS 2025 says both allow improved estimates of peri-procedural risk in severe TR undergoing surgery and possibly help avoid futile interventions.^[1]

Step 3 — Medical therapy

Discussion:

• ESC/EACTS 2025: treat according to the assumed aetiology first, including optimal heart failure treatment and rhythm control for AF, and step up diuretics from a loop diuretic, eventually combined with aldosterone antagonists, thiazides and/or SGLT2 inhibitors.^[1]
• ACC/AHA 2020: in right-sided HF attributable to severe TR (Stages C and D), diuretics can be useful (COR 2a, LOE C-EO), and in right-sided HF attributable to severe secondary TR (Stages C and D), therapies to treat the primary cause of HF, such as rhythm control of AF, can be useful (COR 2a, LOE C-EO).^[3]
• Medical therapy has very limited effect on how TR severity evolves and should not delay evaluation for intervention at an expert centre.^[1]

Step 4 — The decision

Right heart catheterisation shows no pre-capillary PH. RV function is not severely impaired. The Heart Team rates her at high surgical risk, and she remains symptomatic despite optimal medical therapy.^[1]

Discussion:

• ESC/EACTS 2025: transcatheter TV treatment should be considered to improve quality of life and RV remodelling in high-risk patients with symptomatic severe TR despite optimal medical therapy, without severe RV dysfunction or pre-capillary PH (Class IIa, Level A).^[1]
• The Heart Team judges anatomical eligibility for transcatheter therapy, including jet location, coaptation gap, leaflet tethering and possible interference with a pacing lead, and the procedure belongs in an experienced Heart Valve Centre with TV expertise.^[1]
• Tell her what the trials showed: in Tri.Fr (an investigator-initiated, randomised 1:1 trial in 300 adults with severe symptomatic TR in France and Belgium, TEER plus optimised medical therapy versus medical therapy alone), the 1-year composite score improved in 74.1% vs 40.6%, driven by patient-reported outcomes.^[14]
• ESC 2026 heart failure guidance says the randomised trials it cites, of transcatheter treatment in severe symptomatic TR, showed better quality of life with device therapy than with conservative treatment, without fewer deaths or heart failure hospitalisations at 1-year follow-up.^[4]

Step 5 — After TEER

Discussion:

• ESC 2023: antibiotic prophylaxis before oro-dental procedures at increased risk should be considered after transcatheter mitral and tricuspid valve repair (Class IIa, Level C).^[9]
• Patients with moderate or severe TR should be followed clinically and by echo at least every 6 months (ESC/EACTS 2025).^[1]

Assessor marking grid

• Pass: calls the TR secondary with an atrial phenotype; asks for right heart catheterisation and Heart Team review with a risk score; optimises diuretics without delaying referral; quotes the Class IIa, Level A transcatheter row with its conditions; describes a trial by population, design and result.^[1][6][14]
• Fail: relies on the echo PASP, promises a mortality benefit from transcatheter repair on ESC 2026 evidence, or offers transcatheter treatment despite severe RV dysfunction or pre-capillary PH.^[1][4]