Tricuspid regurgitation and stenosis: assessment, surgical timing and transcatheter options

• This page covers tricuspid regurgitation and tricuspid stenosis in adults: causes and phenotypes, grading, work-up, medical therapy, the timing of surgery, transcatheter repair and replacement, and the trials behind them.^[1][2]
• It also gives the rows for leads and pacing at tricuspid surgery, right-sided endocarditis, constrictive pericarditis, pregnancy and antithrombotic therapy after tricuspid repair or replacement.^{[7][8][9][10][19][1]}
• Left-sided lesions are covered in Mitral regurgitation: primary and secondary, Mitral stenosis, Aortic regurgitation and Asymptomatic severe aortic stenosis: timing; echo quantitation in Echocardiographic valve quantitation; congenital tricuspid disease such as Ebstein anomaly in the adult congenital topics, starting at ACHD: anatomy segments and general principles.

Causes and phenotypes

ESC/EACTS 2025 calls TR a common echocardiographic finding, more prevalent in women and older people.^[1] Trivial or mild TR is mostly benign.^[1]

• ACC/AHA 2020 likewise says trace to mild TR is common on TTE with anatomically normal valves, but significant or worsening TR is associated with poor long-term outcomes.^[2]

Significant TR (moderate or more) has a reported age- and sex-adjusted prevalence of 0.55%, and 4% in people aged ≥75 years.^[1] Severe TR is associated with a higher risk of death and heart failure, independent of comorbidities, ventricular function and pulmonary pressures.^[1]

Only 8%–10% of patients with TR have clear anatomical abnormalities of the valve apparatus (primary TR).^[1]

• ESC/EACTS 2025 lists infective endocarditis, rheumatic heart disease, carcinoid syndrome, congenital abnormalities such as Ebstein anomaly, chest radiation, myxomatous disease, and trauma or iatrogenic damage such as endomyocardial biopsy.^[1]

ACC/AHA 2020 adds that a growing number of patients develop significant TR from device leads and endomyocardial biopsies.^[2]

• It says most significant TR is secondary, from annular dilation and leaflet tethering with RV remodelling due to pressure or volume overload, as in pulmonary hypertension or dilated cardiomyopathy.^[2]

There appears to be a subgroup with significant isolated TR mainly from annular dilation, usually with AF, without pulmonary hypertension or LV systolic dysfunction.^[2]

• In secondary TR the leaflets are structurally normal; regurgitation comes from annular dilatation and/or leaflet tethering due to RA dilatation, and/or RV dilation and dysfunction.^[1]

ESC/EACTS 2025 describes two proposed phenotypes of secondary TR.^[1]

• Atrial secondary TR is mainly due to AF: there is no significant leaflet tethering, but marked RA and annular dilatation with preserved RV size and function, pulmonary pressure and LV function.^[1]
• Ventricular secondary TR comes from annular dilatation and leaflet tethering caused by left-sided ventricular or valvular disease (post-capillary PH), pre-capillary PH, or primary RV cardiomyopathy or ischaemia, including after left-sided valve surgery.^[1]

At an advanced stage the two may no longer be distinguishable, so early characterisation is key to outcome.^[1] There is no evidence yet that the phenotype changes management, so current recommendations for intervention consider mainly primary versus secondary TR.^[1]

• A lead may cause TR or be incidental to it: ESC/EACTS 2025 treats CIED-related TR as a separate entity needing a specific diagnostic approach and management.^[1]

In a patient with a CIED, the work-up should clarify whether the lead is the cause (CIED-related TR) or incidental (CIED-associated TR).^[1] ESC 2026 heart failure guidance classifies TR as primary, CIED-related or secondary, with secondary TR the most common.^[4] It gives a prevalence of severe TR of 9%–20% in both HFpEF and HFrEF.^[4]

ACC/AHA 2020 Table 19: Classification of TR

^[2]

• *In that table, isolated TR associated with AF has an LVEF >60%, a pulmonary artery systolic pressure <50 mm Hg, no left-sided valve disease and normal-appearing tricuspid leaflets.^[2]
• ACC/AHA 2020 says AF-related TR appears to represent a fundamentally different pathophysiology, with greater basal dilation and annular enlargement than the RV elongation and leaflet tethering seen when secondary TR is caused by pulmonary hypertension or myocardial disease.^[2]

Tricuspid regurgitation is more prevalent in women, and female sex is associated with faster progression.^[1] ESC/EACTS 2025 suggests the higher prevalence of HFpEF and AF in women as one explanation.^[1] No sex differences in adverse events after surgery or transcatheter TV intervention have been detected to date.^[1]

^[1]

Stages and severity

ACC/AHA 2020 stages TR as it does other valve lesions (Table 20).^[2] Asymptomatic severe TR (Stage C) presents with a raised central venous pressure and imaging evidence of significant TR.^[2] Symptomatic severe TR (Stage D) brings fatigue, abdominal bloating and peripheral oedema.^[2] End-organ damage, such as hepatic and renal failure, is an adverse consequence of Stage D TR that markedly affects survival.^[2] The severity of TR can be dynamic, depending on preload and pulmonary pressure.^[2]

ACC/AHA 2020 Table 20: Stages of TR

^[2]

• ESC/EACTS 2025 asks for severity to be assessed ideally when the patient is euvolaemic, with optimised pulmonary and systemic pressures, by integrating multiple qualitative and quantitative parameters (its Figure 15).^[1]
• A grading scheme beyond severe, adding massive and torrential grades, has been proposed to refine the assessment of TR reduction after transcatheter intervention and has been used in several studies.^[1]
• Although that five-grade scale may track symptoms and event risk, ESC/EACTS 2025 says intervention should be considered without delay as soon as TR is severe, aiming to reduce TR to moderate or less.^[1]

^[2]

Imaging and haemodynamic work-up

Diagnostic rows

^{[3] [6]}

• ESC/EACTS 2025 says echocardiography is recommended to assess TR: severity and aetiology, including left-sided disease and any CIED lead and its interaction with the valve, the effect on RV and RA size and function, and central venous and pulmonary pressures.^[1]

Transthoracic echo gives enough information in most patients.^[1]

• ACC/AHA 2020 says TTE can distinguish primary TR (abnormal leaflets) from secondary TR (normal leaflets), define any associated left-sided disease and estimate pulmonary artery systolic pressure.^[2]

Grading relies on an integrative assessment of multiple parameters, but many limitations remain.^[2]

• In TR at left-sided valve surgery, an annular diastolic diameter >40 mm (or >21 mm/m²) indicates a higher risk of persistent or progressive TR after isolated mitral surgery.^[2]

In candidates for intervention, advanced techniques such as strain analysis and 3D echocardiography should also be applied when available.^[1] When accurate RV size, function and volume are needed for a decision, CMR should be used because of its accuracy and reproducibility.^[1]

• In severe TR, RV function is often overestimated, so ESC/EACTS 2025 suggests the most conservative thresholds for RV dysfunction, and gives cut-offs for severe RV dysfunction to flag high-risk or possibly futile intervention (Figure 15 of the guideline).^[1]
• ACC/AHA 2020 text defines normal RV systolic function by several parameters, including TAPSE >16 mm, tricuspid systolic annular velocity >10.0 cm/s, and RV end-systolic area <20.0 cm² or fractional area change >35%.^[2]

Echo often underestimates pulmonary pressures in severe TR.^[1]

• ESC/EACTS 2025 therefore says right heart catheterisation is recommended in all candidates for an intervention, to assess the haemodynamic effect on the RA and venous circulation, measure RV end-diastolic pressure and document volume overload.^[1]

Pulmonary pressures and vascular resistance are key to excluding masked severe pre-capillary PH.^[1] ACC/AHA 2020 notes that a weak TR signal or severe TR may underestimate pulmonary systolic pressure, and direct invasive measurement can resolve this.^[2]

• It adds that thermodilution cardiac output may be inaccurate with severe TR, so a Fick cardiac output should be used for the pulmonary resistance calculation.^[2]

• ESC/ERS 2022 warns that correcting TR in PAH, or in PH with non-valvular left heart disease and a markedly raised PVR and/or RV dysfunction, must be considered with great caution, as it may be hazardous.^[6]

• RV–pulmonary artery coupling is the ability of RV systolic performance to match a given afterload; it can be measured invasively or approximated on echo as TAPSE/SPAP.^[1]

• Uncoupling (a low TAPSE/SPAP) has been associated with poor prognosis in heart failure, including severe TR; it is not yet prospectively validated but may improve risk stratification.^[1]

• ECG-gated CT with dedicated right-heart protocols defines the RA, RV, venae cavae and right coronary artery, and is crucial for suitability and sizing for several transcatheter devices.^[1]

Risk scores and the Heart Team

ESC/EACTS 2025 sets out the steps in its Figure 16 (stepwise evaluation of patients with TR).^[1]

• In patients with severe TR, ESC/EACTS 2025 recommends careful evaluation by a multidisciplinary Heart Team of TR aetiology, disease stage (TR severity, RV and LV dysfunction, PH), operative risk and the likelihood of recovery before intervention (Class I, Level C).^[1]
• The TRI-SCORE and the STS isolated TV risk calculator include clinical and echo signs of RV dysfunction and secondary organ impairment, particularly hepatic and renal.^[1]

Both improve estimates of peri-procedural risk in severe TR surgery and may help avoid futile intervention.^[1]

• ESC/EACTS 2025 reports a registry analysis of 2413 patients with severe TR comparing any intervention with conservative management: early intervention (transcatheter repair or surgery) was associated with better mid-term survival with a low or intermediate TRI-SCORE (up to 5 points), with no benefit at a high TRI-SCORE (≥6).^[1]

Patients with moderate or severe TR should be followed clinically and by echo at least every 6 months.^[1] Its key messages say risk scores for RV and secondary organ dysfunction should be strongly encouraged in isolated severe TV disease.^[1]

Coronary disease before valve surgery

• In patients with a primary indication for valve surgery, ESC/EACTS 2025 recommends CABG for coronary stenosis ≥70% (Class I, Level C; stenosis ≥50% can be considered for the left main) and says CABG should be considered for stenosis of ≥50%–70% (Class IIa, Level C).^[1]

Medical therapy

• ESC/EACTS 2025 says relevant TR is first treated according to its assumed aetiology, including optimal heart failure treatment, pulmonary vasodilators for PH and rhythm control for AF.^[1]

With heart failure symptoms, diuretics are started stepwise, beginning with loop diuretics, eventually combined with aldosterone antagonists, thiazides and/or SGLT2 inhibitors.^[1]

• According to current knowledge, medical therapy has very limited effect on how TR severity evolves, and none of these measures should delay evaluation for intervention at an expert centre.^[1]

Medical therapy rows

^[3]

• ACC/AHA 2020 text adds that a low-salt diet and support stockings may help, and that loop diuretics are typically given and may relieve congestion, but their use can be limited by worsening low-flow syndrome.^[2]

Aldosterone antagonists may add benefit, especially with hepatic congestion, which may promote secondary hyperaldosteronism.^[2] Restoring sinus rhythm may help secondary TR due to annular dilation with AF.^[2]

• The 2022 AHA/ACC/HFSA heart failure synopsis says secondary TR severity may be dynamic and that management focuses on underlying causes, such as pulmonary hypertension, RV failure and HFrEF.^[5]

It adds that referral to the multidisciplinary team for consideration of intervention might be helpful in refractory TR (no class or level given).^[5]

• ESC 2026 heart failure guidance says medical therapy to target TR is limited and refers indications for TR treatment to the ESC/EACTS 2025 valve guideline (no class or level given).^[4]

TR at the time of left-sided valve surgery

• Severe primary or secondary TR is unlikely to improve after isolated surgery on the left-sided valve, and reoperation for TR carries high peri-operative mortality, so ESC/EACTS 2025 recommends TV surgery at the index procedure.^[1]

ACC/AHA 2020 gives a perioperative mortality of 10% to 25% for reoperation for severe isolated TR after left-sided valve surgery.^[2]

Concomitant tricuspid surgery

^{[1] [3] [2]}

In the ESC/EACTS table, TV surgery means valve repair whenever possible.^[1] Its Figure 17 footnote asks for repair whenever possible, particularly for moderate TR or mild TR with significant annular dilatation.^[1]

• ESC/EACTS 2025 says mild TR with significant annular dilatation, or moderate TR, left uncorrected at left-sided surgery progresses in about one-quarter of patients and is associated with worse outcome.^[1]

ACC/AHA 2020 similarly says uncorrected mild or moderate secondary TR may progress in about 25% and reduce long-term function and survival.^[2]

• ACC/AHA 2020 lists annular dilation, RV dysfunction or remodelling, leaflet tethering height, pulmonary hypertension, AF and intra-annular RV pacemaker or ICD leads as risk factors for persistent or progressive TR.^[2]

• It says that, because TR severity may be dynamic, a past history of signs or symptoms of right-sided heart failure indicates a propensity to more severe TR and should be considered an indication for concomitant tricuspid valve repair.^[2]

• For moderate TR, ESC/EACTS 2025 says annuloplasty during mitral surgery should be considered, and reports that large retrospective studies and two recent RCTs in this setting showed benefit on TR progression and RV remodelling over time.^[1]

No effects on mortality, heart failure events or reoperation were seen in the repair group.^[1] Concomitant repair has been associated with more conduction disturbance needing a pacemaker (up to 14%), with potential negative effects on longer-term outcomes.^[1] For mild TR with annular dilatation, earlier observational studies showed benefit on progression and RV function and a trend to better long-term survival.^[1]

• It reports that a subanalysis of a recent RCT found no difference in TR progression or other outcomes over 2 years of follow-up in patients with mild TR and annular dilatation at left-sided surgery.^[1]

ESC/EACTS 2025 adds that the need for a pacemaker after surgery led to more heart failure hospitalisations, endocarditis and mortality.^[1]

• Annuloplasty may therefore be considered after careful evaluation of the risk factors for progressive annular dilatation and TR (for example AF, RA size and pulmonary pressures), weighed against the risk of possible pacemaker implantation.^[1]

The 2021 rows that the 2025 concomitant rows replaced (dated history)

^[1]

• ESC/EACTS 2025 merged primary and secondary TR in the severe and moderate grades (its mild-TR row covers secondary TR only), and its key messages call concomitant TV repair the preferred method for moderate or severe TR at left-sided valve surgery.^[1]

^{[17] [3] [1]}

Isolated severe TR

Patients are often referred for surgery too late, after significant RV and other organ failure.^[1]

• ESC/EACTS 2025 says isolated TV surgery has been considered generally high risk, with in-hospital mortality of 8%–10% in several reports, but contemporary cohorts referred earlier and treated with more effective techniques have done better.^[1]

ACC/AHA 2020 cites a reported operative mortality of up to 8% to 20% for severe isolated TR, mostly in patients already with end-organ damage.^[2]

ESC/EACTS 2025 Recommendation Table 9: severe TR without left-sided valve disease needing surgery

^[1]

The table defines TV surgery as valve repair whenever possible.^[1]

• ESC/EACTS 2025 says that patients with severe LV or RV dysfunction or PH do not qualify for isolated TV surgery because of high operative risk.^[1]

Annuloplasty-ring repair is preferred over replacement when technically feasible, especially at low risk with suitable anatomy.^[1] Replacement may be needed with advanced disease, marked annular dilatation and leaflet tethering.^[1] ACC/AHA 2020 also calls repair preferable, but says replacement may be necessary with marked annular dilation or intrinsic disease of the leaflets.^[2] Key message: in isolated severe TR without severe RV dysfunction, surgery should be done early in patients at low operative risk.^[1]

ACC/AHA 2020 timing rows for isolated TR

^[3]

ACC/AHA 2020 says treatment of secondary TR is targeted at pulmonary hypertension or myocardial disease.^[3] It notes renewed interest in earlier surgery for severe isolated TR before severe RV dysfunction or end-organ damage.^[3] ACC/AHA 2020 says the optimal timing of surgery in asymptomatic or minimally symptomatic severe primary TR has not been established.^[2]

• In otherwise healthy patients, such as those with traumatic severe TR, it puts the operative mortality at <1% to 2% without RV dysfunction or pulmonary hypertension.^[2]

For isolated TR in selected patients it reports an acceptable operative mortality (<4% to 5%) with newer surgical techniques and a better selection process.^[2] With severe symptomatic primary TR from device leads or biopsy, TR develops rapidly and surgery can be done before RV dysfunction sets in.^[2]

^[1]

Transcatheter repair and replacement

ESC 2026 heart failure guidance says transcatheter devices give an alternative to surgery in selected patients.^[4] Transcatheter options include TEER, direct annuloplasty, and orthotopic and heterotopic TV replacement.^[1]

• ESC/EACTS 2025 says registries, single-arm trials and two RCTs in severe TR at intermediate and high surgical risk show transcatheter repair is safe and can reduce TR to moderate or less in more than 80% when anatomy is suitable.^[1]

The Heart Team judges anatomical eligibility, including jet location, coaptation gap, leaflet tethering and possible interference with a pacing lead (Figure 17 footnote).^[1]

• Procedures should be done at an experienced Heart Valve Centre with expertise in TV disease, and the guideline lists all tricuspid procedures among the complex procedures ideally performed in the most experienced Heart Valve Centres (Table 6).^[1]

How the transcatheter row changed

^[1]

• ESC/EACTS 2025 reports that TRILUMINATE, a randomised trial of tricuspid TEER against medical therapy in symptomatic severe TR, showed a lower incidence of its 1-year composite of death or TV surgery, heart failure hospitalisation and quality of life, driven only by quality of life (KCCQ 11.7 points; 95% CI 6.8–16.6).^[1][12]

At 2 years fewer heart failure hospitalisations were seen with TEER, despite 59% crossover.^[1]

• It reports that Tri.Fr, an investigator-initiated RCT of TEER with GDMT against medical therapy alone in severe symptomatic TR, showed benefit on a 1-year composite score driven by patient-reported outcomes.^[1][14]
• It reports that TRISCEND II, an RCT of transcatheter TV replacement against optimised medical therapy in symptomatic severe TR, favoured replacement on a 1-year win ratio mainly through symptoms and quality of life, with reverse RV remodelling seen in these studies.^[1][15]
• ESC/EACTS 2025 reports that transcatheter TV replacement had a less favourable safety profile, including a higher risk of major bleeding (15%) and post-procedural pacemaker implantation in about one-quarter of pacemaker-naive patients after 12 months of follow-up.^[1]
• On these data ESC/EACTS 2025 says transcatheter 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.^[1]

Where several valves need transcatheter treatment, a staged approach usually starting with the downstream lesion (aortic, then mitral, then tricuspid) is generally preferred.^[1]

^{[12] [13] [14] [15]}

• ESC 2026 heart failure guidance says three RCTs of transcatheter treatment in severe symptomatic TR showed better quality of life with device therapy, without fewer deaths or heart failure hospitalisations at 1 year.^[4]

It notes a possible benefit on heart failure hospitalisation with tricuspid TEER, but with high crossover after 1 year.^[4] All these studies were unblinded and did not focus on HFpEF or HFrEF populations.^[4]

^[16]

• TRIC-I-HF was published online after the ESC 2026 heart failure guideline and is not cited in it; no guideline row on this page draws on it.

• ESC/EACTS 2025 says transvenous lead repositioning or extraction can be considered in selected patients to improve TR or avoid lead jailing before a tricuspid intervention, although efficacy is uncertain and the risk of damaging the valve is not negligible.^[1]

• Recurrent TR after annuloplasty usually needs reoperation for surgical TV replacement, and transcatheter valve-in-ring implantation is an off-label option for residual TR in high-risk patients.^[1]

• Transcatheter transvenous mitral or tricuspid valve-in-valve implantation should be considered for significant valve dysfunction at intermediate or high surgical risk, if the anatomy is suitable (ESC/EACTS 2025, Class IIa, Level B).^[1]

^{[12] [16] [14] [15]}

Leads, pacing and tricuspid surgery

• For CIED-related TR, ESC/EACTS 2025 says freeing an entrapped leaflet and possibly lead extraction with an epicardial system has been associated with better valve function.^[1]
• ESC 2021 pacing guidance calls trans-tricuspid pacemaker or ICD leads an underestimated aspect of surgical management, as they can interfere with a repaired valve or a prosthesis.^[7]
• ACC/AHA/HRS 2018 notes that the AV node lies between the anterior and septal leaflets, making it particularly susceptible to injury with any tricuspid valve intervention.^[8]
• Its text gives pacemaker implantation rates after valve surgery of 12% for tricuspid alone, 16% for mitral plus tricuspid and 25% for combined aortic, mitral and tricuspid surgery.^[8]

Pacing at and after tricuspid surgery

^{[7] [8] [9]}

• ESC 2021 adds that His-bundle pacing may become an option for AV conduction disease after tricuspid surgery; pacing indications are covered in Bradycardia and pacing indications.^[7]

Endocarditis, constriction, pulmonary hypertension and pregnancy

Right-sided endocarditis

Surgery for right-sided infective endocarditis

^[9]

Tricuspid valve repair should be considered instead of replacement when possible (ESC 2023, Class IIa, Level B).^[9] Endocarditis is covered in full in Infective endocarditis.

Constrictive pericarditis

• In constriction, ESC 2025 pericarditis guidance says TR is common, from chronically raised right-sided pressures, annular dilation from long-standing volume overload and atrial enlargement, and leaflet tethering by the pericardium.^[10]
• ESC 2025 reports that, when TR is present at pericardiectomy, leaving the valve unrepaired can lead to persistent right heart failure symptoms, poorer functional recovery after surgery and higher long-term mortality, as shown in retrospective observational studies.^[10]

ESC 2025 recommends tricuspid valve repair in patients with pericardial constriction and severe TR to improve symptoms and survival (Class I, Level C).^[10]

• Its supporting text limits this to concomitant repair at pericardiectomy: "repair is recommended when TR is more than mild, and anatomy is suitable, and the patient is already undergoing pericardiectomy (i.e. no added surgery is required beyond access). Supporting evidence is limited."^[10]
• It adds that RCTs are lacking and that the recommendation is based on retrospective findings of improved symptom relief and outcomes with combined surgery, on surgical principles and on the practicality and safety of repair when the chest is already open.^[10]

Pulmonary hypertension

• ESC/ERS 2022 says severe TR is associated with volume overload, increased RV workload and maladaptive remodelling, leading to symptomatic right heart failure and impaired survival.^[6]

• It says patient selection appears crucial and that imaging plus invasive haemodynamic assessment is needed before tricuspid repair, particularly as echo underestimates sPAP in severe TR.^[6]

• Pulmonary hypertension itself is covered in Pulmonary hypertension: the five groups; ESC/ERS 2022 recommends right heart catheterisation in severe TR, with or without left heart disease, before surgical or interventional valve repair (Class I, Level C).^[6]

Pregnancy

• ESC 2025 pregnancy guidance says medical treatment for TR is usually not required, but diuretics and rhythm management may be needed in pregnancy (no class or level given).^[19]

Surgery for isolated TR in pregnancy is rarely indicated except with endocarditis.^[19] Diuretics are recommended in pregnant women with regurgitant lesions when symptoms or signs of congestion occur (Class I, Level C).^[19] Valve surgery during pregnancy should only be considered when there is a maternal mortality risk and other options have failed (Class IIa, Level C).^[19]

Antithrombotic therapy and prophylaxis after tricuspid intervention

After repair or replacement

^{[1] [9] [11]}

• The ESC/EACTS 2025 repair row replaced the 2021 row on a VKA for the first 3 months after mitral and tricuspid repair (Class IIa, Level C; Table 4).^[1]

Data on antithrombotic therapy after transcatheter mitral or tricuspid bioprostheses are limited.^[1] Valve prostheses are covered in Prosthetic valves.

• After transcatheter mitral or tricuspid valve implantation in patients not already on OAC, ESC/EACTS 2025 says OAC (DOAC or VKA) is started and usually continued for at least 6 months or indefinitely, particularly in the tricuspid position, while TEER patients usually receive long-term single antiplatelet therapy with aspirin.^[1]

Tricuspid stenosis

ESC/EACTS 2025 calls TS relatively rare, most often linked to congenital conditions or enzymatic disorders such as Whipple’s or Fabry’s disease.^[1] It can be acquired as an isolated feature of rheumatic heart disease or with aortic and/or mitral involvement.^[1] TS can also be the consequence of carcinoid disease, through serotonin-mediated proliferation on the leaflets and subvalvular apparatus.^[1] Rare causes are drugs such as fenfluramine or methysergide, and inflow obstruction from CIED-associated thrombus or endocarditis with large vegetations.^[1]

Diagnosis rests on echocardiography of the leaflets and subvalvular apparatus.^[1] Leaflet thickening, with or without calcification, and commissural fusion are pathognomonic of rheumatic involvement.^[1] A mean diastolic transvalvular gradient >5 mmHg at a normal heart rate indicates severe TS.^[1] Medical therapy is a bridge to intervention: intensive sodium restriction with diuretics can improve symptoms and hepatic congestion.^[1]

Recommendation Table 10: intervention in tricuspid stenosis

^[1]

In that table, surgery usually means TV replacement.^[1] Repair is preferred in younger patients, but replacement is often needed.^[1]

• Bioprostheses are preferred over mechanical valves because of high thrombogenicity in this low-pressure system, and valve-in-valve is a good alternative to re-replacement when a bioprosthesis degenerates.^[1]

Transcatheter TV implantation for TS has limited experience.^[1] In carcinoid disease, a stable oncological situation is a prerequisite for any valve intervention.^[1]

• Balloon valvuloplasty can be an option in selected TS without relevant TR, or with combined rheumatic mitral and tricuspid disease, although data are very limited.^[1]

Unlike rheumatic mitral stenosis, rheumatic tricuspid disease more often presents as combined stenosis and regurgitation, which limits the use of balloon valvuloplasty.^[1]

• ESC/EACTS 2025 key messages: TS is very rare as acquired valve disease in high-income countries, is mainly rheumatic, carcinoid or enzymatic, and is treated mainly by surgical TV replacement when symptomatic.^[1]

Severe combined TS and TR needing surgery is listed among the contraindications to percutaneous mitral commissurotomy (ESC/EACTS 2025 Table 8).^[1]

Pitfalls

• Grading TR while the patient is congested: ESC/EACTS 2025 asks for assessment ideally in euvolaemia with optimised pressures, and ACC/AHA 2020 notes that TR severity can be dynamic, depending on preload and pulmonary pressure.^[1][2]
• Trusting the echo PASP in severe TR: ESC/EACTS 2025 notes that echo often underestimates pulmonary pressures in severe TR, and ESC/ERS 2022 recommends right heart catheterisation in severe TR, with or without left heart disease, before surgical or interventional valve repair (Class I, Level C).^[1][6]
• Using thermodilution cardiac output in severe TR: ACC/AHA 2020 says it may be inaccurate and asks for a Fick cardiac output.^[2]
• Leaving moderate primary or secondary TR at left-sided valve surgery: concomitant TV repair should be considered to avoid progression of TR and RV remodelling (ESC/EACTS 2025, Class IIa, Level B), weighing the pacemaker risk of up to 14% after concomitant repair.^[1]
• Waiting for end-stage RV failure: ESC/EACTS 2025 says patients are often referred too late, and that for isolated TV surgery patients with severe LV or RV dysfunction or PH do not qualify because of high operative risk.^[1]
• Reading the transcatheter trials as mortality trials: TRILUMINATE, a prospective randomised trial, assigned 350 patients with symptomatic severe TR 1:1 to TEER or medical therapy, and its abstract reports that death or tricuspid surgery and heart failure hospitalisation did not appear to differ; the 2-year TRILUMINATE report says the 1-year outcomes showed similar rates of mortality and heart failure hospitalisation; ESC/EACTS 2025 reports that the benefit on the primary composite was driven exclusively by improved quality of life.^[12][13][1]
• Passing a transvalvular lead after mechanical TV replacement: ESC 2021 says to avoid it (Class III, Level C).^[7]

Evidence, guidelines and regional differences

^{[1] [3] [2]}

• The two agree on treating severe TR at left-sided surgery; they differ on less-than-severe TR at left-sided surgery (ESC/EACTS 2025 gives rows for moderate TR and for mild secondary TR with annular dilatation; ACC/AHA 2020 gives one row for progressive TR, Stage B, with annular dilation or prior right-sided HF) and on transcatheter therapy, which of the two only ESC/EACTS 2025 grades.^[1][3][2]
• ESC/EACTS 2025 moved transcatheter treatment from 'may be considered' (Class IIb, Level C) for symptomatic secondary severe TR in inoperable patients at a Heart Valve Centre with expertise in the treatment of TV disease (2021) to 'should be considered to improve quality of life and RV remodelling' (Class IIa, Level A) in high-risk patients with symptomatic severe TR despite optimal medical therapy, without severe RV dysfunction or pre-capillary PH.^[1]

Gaps in evidence

• ESC/EACTS 2025 lists as unresolved the long-term risks and benefits of concomitant TV surgery in less than moderate TR with annular dilatation at left-sided surgery.^[1]

• It asks for outcomes of TV intervention in asymptomatic severe TR with RV dysfunction or significant dilation.^[1]

• For TS, the role of transcatheter TV replacement is unexplored, as is the most efficient way to pace the ventricle after TV replacement.^[1]

• ESC/EACTS 2025 says the evidence for treating TV disease is growing, including new randomised data supporting concomitant TV repair at left-sided valve surgery, and transcatheter options (repair and replacement) that reduce TR, promote reverse RV remodelling and improve quality of life compared with medical treatment.^[1]

In Australia and New Zealand

• No Australian or New Zealand guideline row on TR is used here; the 2024 CSANZ TTE position statement is quoted only from its PubMed abstract, whose stated objectives are a guiding framework for treating clinicians of the acceptable indications for initial and serial TTE assessment of the commonly encountered cardiovascular conditions in adults, and the minimum required standard for TTE examinations and reporting.^[18]
• The documents below are those with a held-status entry in the census for this topic.
• The 2024 CSANZ Position Statement on Indications, Assessment and Monitoring of Structural and Valvular Heart Disease With Transthoracic Echocardiography in Adults (PMID 38749800) is not held as text in its version of record, so it was not checked for this topic; only its PubMed abstract is quotable.
• The NHFA/CSANZ Australian Clinical Guidelines for the Diagnosis and Management of Atrial Fibrillation 2018 (PMID 30077228) are not held as text in their version of record, so they were not checked for this topic.
• The NHFA/CSANZ Comprehensive Australian Clinical Guideline for Diagnosing and Managing Acute Coronary Syndromes 2025 (PMID 40180468) is not held as text in its version of record, so it was not checked for this topic.
• Only the PubMed abstract of the 2023 Australian guideline for assessing and managing cardiovascular disease risk (PMID 38623719) is held; its full text is not held and was not checked for this topic.
• Only the PubMed abstract of the A summary of the 2023 Society of Obstetric Medicine of Australia and New Zealand (SOMANZ) hypertension in pregnancy guideline (PMID 38763516) is held; its full text is not held and was not checked for this topic.

Guidelines checked for this topic

• Rows on this page come from the ESC/EACTS 2025 valvular heart disease, ESC 2026 heart failure, ESC 2025 myocarditis and pericarditis, ESC 2025 pregnancy, ESC 2023 endocarditis, ESC/ERS 2022 pulmonary hypertension, ESC 2022 non-cardiac surgery and ESC 2021 pacing guidelines.^{[1][4][10][19][9][6][11][7]}

• AHA/ACC rows come from the 2020 ACC/AHA valvular heart disease guideline, the 2018 ACC/AHA/HRS bradycardia guideline and the 2022 AHA/ACC/HFSA heart failure guideline.^[3][8][5]

• Study results are quoted from the PubMed abstracts of TRILUMINATE (primary and 2-year reports), Tri.Fr, TRISCEND II, TRIC-I-HF and the CTSN concomitant tricuspid repair trial.^{[12][13][14][15][16][17]}

• For the rows on this page, the same-month and newer guidelines in the census below were checked and give no revising row, except where a newer row is shown in its place (census 2026-10-23).

• Expert consensus documents on TR found in the PubMed census, such as the 2025 ACC expert consensus decision pathway on TR (PMID 40981727), are not guidelines, are not held as text and were not used.

• The documents in this list are not used; each line gives the held status recorded in the census for this topic.

• The 2021 ESC/EACTS Guidelines for the management of valvular heart disease (PMID 34453165) are not held as text in the evidence caches, so they were not checked for this topic.

• Only the PubMed abstract of the 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary (PMID 33332149) is held; its full text is not held and was not checked for this topic.

• The Multi-modality imaging assessment of native valvular regurgitation: an EACVI and ESC council of valvular heart disease position paper (PMID 35292799) is not held as text in the evidence caches, so it was not checked for this topic.

• The role of multi-modality imaging in multiple valvular heart diseases: a clinical consensus statement of the European Association of Cardiovascular Imaging of the European Society of Cardiology (PMID 39874243) is not held as text in the evidence caches, so it was not checked for this topic.

• Only the PubMed abstract of the Guidelines for the Echocardiographic Assessment of the Right Heart in Adults and Special Considerations in Pulmonary Hypertension: Recommendations from the American Society of Echocardiography (PMID 40044341) is held; its full text is not held and was not checked for this topic.

• Only the PubMed abstract of the Echocardiographic assessment of aortic stenosis: a practical guideline from the British Society of Echocardiography (PMID 33709955) is held; its full text is not held and was not checked for this topic.

• The Multi-modality imaging in aortic stenosis: an EACVI clinical consensus document (PMID 37395329) is not held as text in the evidence caches, so it was not checked for this topic.

• The Management of aortic stenosis and chronic heart failure: A clinical consensus statement of the Heart Failure Association (HFA) and the European Association of Percutaneous Cardiovascular Interventions (EAPCI) of the ESC (PMID 40948025) is not held as text in the evidence caches, so it was not checked for this topic.

• The 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure (PMID 34447992) are not held as text in the evidence caches, so they were not checked for this topic.

• The 2023 Focused Update of the 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure (PMID 37622666) are not held as text in the evidence caches, so they were not checked for this topic.

• Only the PubMed abstract of the Pulmonary hypertension associated with left heart disease (PMID 39209478) is held; its full text is not held and was not checked for this topic.

• Only the PubMed abstract of the European Respiratory Society clinical practice guidelines update for the treatment of pulmonary arterial hypertension (PMID 42705705) is held; its full text is not held and was not checked for this topic.

• The JCS/JPCPHS 2025 Guideline on Pulmonary Hypertension and Pulmonary Embolism/Deep Vein Thrombosis (PMID 42386545) is not held as text in the evidence caches, so it was not checked for this topic.

• Only the PubMed abstract of the 2026 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery (PMID 42804570) is held; its full text is not held and was not checked for this topic.

• The 2018 ESC/EACTS Guidelines on myocardial revascularization (PMID 30165437) are not held as text in the evidence caches, so they were not checked for this topic.

• The 2019 ESC Guidelines for the diagnosis and management of chronic coronary syndromes (PMID 31504439) are not held as text in the evidence caches, so they were not checked for this topic.

• The 2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation (PMID 32860058) are not held as text in the evidence caches, so they were not checked for this topic.

• The 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation (PMID 32860505) are not held as text in the evidence caches, so they were not checked for this topic.

• The 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization (PMID 34882435) is not held as text in the evidence caches, so it was not checked for this topic.

• The 2022 ESC Guidelines on cardio-oncology (PMID 36017568) are not held as text in the evidence caches, so they were not checked for this topic.

• Only the PubMed abstract of the 2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease (PMID 38743805) is held; its full text is not held and was not checked for this topic.

• The 2026 ESC Guidelines for the management of cardiovascular disease and chronic kidney disease, in collaboration with the European Renal Association (ERA) (PMID 42661426) are not held as text in their version of record, so they were not checked for this topic.

• The 2018 AHA/ACC Guideline for the Management of Adults With Congenital Heart Disease (PMID 30121239) is not held as text in the evidence caches, so it was not checked for this topic.

• The PACES/HRS Expert Consensus Statement on the Recognition and Management of Arrhythmias in Adult Congenital Heart Disease: developed in partnership between the Pediatric and Congenital Electrophysiology Society (PACES) and the Heart Rhythm Society (HRS). Endorsed by the governing bodies of PACES, HRS, the American College of Cardiology (ACC), the American Heart Association (AHA), the European Heart Rhythm Association (EHRA), the Canadian Heart Rhythm Society (CHRS), and the International Society for Adult Congenital Heart Disease (ISACHD) (PMID 24814377) is not held as text in the evidence caches, so it was not checked for this topic.

• The PACES/HRS expert consensus statement on the use of catheter ablation in children and patients with congenital heart disease: Developed in partnership with the Pediatric and Congenital Electrophysiology Society (PACES) and the Heart Rhythm Society (HRS). Endorsed by the governing bodies of PACES, HRS, the American Academy of Pediatrics (AAP), the American Heart Association (AHA), and the Association for European Pediatric and Congenital Cardiology (AEPC) (PMID 26899545) is not held as text in the evidence caches, so it was not checked for this topic.

• The Recommendations for participation in competitive sport in adolescent and adult athletes with Congenital Heart Disease (CHD): position statement of the Sports Cardiology & Exercise Section of the European Association of Preventive Cardiology (EAPC), the European Society of Cardiology (ESC) Working Group on Adult Congenital Heart Disease and the Sports Cardiology, Physical Activity and Prevention Working Group of the Association for European Paediatric and Congenital Cardiology (AEPC) (PMID 32845299) is not held as text in the evidence caches, so it was not checked for this topic.

• The HRS/ISACHD/PACES scientific statement on provider and institutional best practices for comprehensive adult congenital heart disease electrophysiology programs (PMID 41679448) is not held as text in the evidence caches, so it was not checked for this topic.

• The held guidelines below were checked, and no row from them is used here; each line gives the reason.

• Adult congenital guidelines (ACC/AHA/HRS/ISACHD/SCAI 2025, PMID 41411375; ESC 2020, PMID 32860028) and the ESC 2025 pregnancy row on women with a systemic RV and severe TR: their tricuspid rows concern congenital lesions, such as Ebstein anomaly, the systemic tricuspid valve and TR with pulmonary stenosis or repaired tetralogy, which belong to the adult congenital topics.

• ESC 2024 chronic coronary syndromes (PMID 39210710): its statement on CABG at aortic, mitral or tricuspid valve surgery is narrative without a class, and the newer ESC/EACTS 2025 revascularisation rows are given above.^[1]

• Rhythm guidelines: ACC/AHA/ACCP/HRS 2023 AF (PMID 38033089) names AF as a cause of TR in narrative only; ESC 2024 AF (PMID 39210723) mentions the tricuspid valve only as the cavotricuspid isthmus; ESC 2019 (PMID 31504425) and ACC/AHA/HRS 2015 (PMID 26399663) SVT, ESC 2022 (PMID 36017572) and AHA/ACC/HRS 2017 (PMID 29084731) ventricular arrhythmia and ACC/AHA/HRS 2017 syncope (PMID 28280231) guidelines mention Ebstein anomaly or the tricuspid annulus as arrhythmia substrates.

• Sports guideline: ESC 2020 sports cardiology (PMID 32860412) has a narrative section on TR in athletes, with no recommendation table on TR, so no row from it is used.

• NHFA/CSANZ 2018 heart failure (Heart Lung Circ, PMID 30077227; Med J Aust summary PMID 30067937): isolated tricuspid valve pathology is named only as a rare cause of right heart failure, and TR velocity as an echo criterion, with no TR row.

• ESC 2023 cardiomyopathies (PMID 37622657), AHA/ACC 2024 perioperative (PMID 39316661; replaced by the 2026 edition listed above), the 2024 World Symposium pulmonary hypertension documents (PMIDs 39209475, 39209476), ESC 2019 (PMID 31504429) and AHA/ACC 2026 (PMID 41712677) pulmonary embolism, and AHA/ASA 2021 secondary stroke prevention (PMID 34024117): TR or tricuspid indices appear only in narrative, echo criteria or reference lists, with no TR row.

• Aortic guidelines (ESC 2024, PMID 39210722; ACC/AHA 2022, PMID 36322642): “tricuspid” refers to the tricuspid aortic valve, and TS to Turner syndrome.

• AHA/ACC 2025 competitive sports statement (PMID 39973614): Ebstein anomaly and dysplastic tricuspid valve in athletes, a population outside this topic; 2024 Australia-New Zealand cardiac amyloidosis consensus (PMID 38570258) and AHA 2021 mechanical complications of MI statement (PMID 34126755): no TR row.

• Coronary, lipid, prevention, hypertension, diabetes, kidney-metabolic, hypertrophic cardiomyopathy, chest pain, cardiac rehabilitation and myocardial infarction definition guidelines in the register (PMIDs 37471501, 37622654, 40014670, 41693087, 30571511, 42661425, 31504418, 40878289, 41824552, 34458905, 39210715, 40811497, 37622663, 42263157, 38718139, 34709879, 42661418): the census sweep found no tricuspid valve wording outside reference lists.

Exam pearls

• Primary TR is the minority: only 8%–10% of TR has clear anatomical abnormality of the apparatus (ESC/EACTS 2025).^[1]
• Annulus thresholds at left-sided valve surgery: ESC/EACTS 2025 says concomitant TV repair may be considered in selected patients with mild secondary TR and an annulus ≥40 mm or >21 mm/m² (IIb B); ACC/AHA 2020 says tricuspid valve surgery can be beneficial in progressive TR (Stage B) with an annulus end-diastolic diameter >4.0 cm or prior right-sided HF (2a B-NR).^[1][3]
• Stage C or D TR on ACC/AHA 2020 Table 20: central jet ≥50% RA, vena contracta ≥0.7 cm, ERO ≥0.40 cm², regurgitant volume ≥45 mL, dense triangular CW signal and hepatic vein systolic flow reversal.^[2]
• Severe TS: mean diastolic gradient >5 mmHg at a normal heart rate (ESC/EACTS 2025).^[1]
• TRI-SCORE: no benefit from intervention over conservative care at ≥6 points in the registry analysis reported by ESC/EACTS 2025 (2413 patients with severe TR, mid-term survival).^[1]
• TRISCEND II (randomised 2:1, 400 patients with severe symptomatic TR) safety: severe bleeding in 15.4% and a new permanent pacemaker in 17.4% with transcatheter tricuspid-valve replacement plus medical therapy, versus 5.3% and 2.3% with medical therapy alone.^[15]

References19ShowHide

1. [1]Praz F, et al. 2025 ESC/EACTS Guidelines for the management of valvular heart disease. Eur Heart J, 2025.PMID 40878295
2. [2]Otto CM, et al. 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation, 2021.PMID 33332150
3. [3]Otto CM, et al. 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol, 2021.PMID 33342586
4. [4]Køber L, et al. 2026 ESC Guidelines for the management of heart failure. Eur Heart J, 2026.PMID 42661420
5. [5]Heidenreich PA, et al. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation, 2022.PMID 35363499
6. [6]Humbert M, et al. 2022 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension. Eur Heart J, 2022.PMID 36017548
7. [7]Glikson M, et al. 2021 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy. Eur Heart J, 2021.PMID 34455430
8. [8]Kusumoto FM, et al. 2018 ACC/AHA/HRS Guideline on the Evaluation and Management of Patients With Bradycardia and Cardiac Conduction Delay: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol, 2019.PMID 30412709
9. [9]Delgado V, et al. 2023 ESC Guidelines for the management of endocarditis. Eur Heart J, 2023.PMID 37622656
10. [10]Schulz-Menger J, et al. 2025 ESC Guidelines for the management of myocarditis and pericarditis. Eur Heart J, 2025.PMID 40878297
11. [11]Halvorsen S, et al. 2022 ESC Guidelines on cardiovascular assessment and management of patients undergoing non-cardiac surgery. Eur Heart J, 2022.PMID 36017553
12. [12]Sorajja P, et al. Transcatheter Repair for Patients with Tricuspid Regurgitation. N Engl J Med, 2023.PMID 36876753
13. [13]Kar S, et al. Two-Year Outcomes of Transcatheter Edge-to-Edge Repair for Severe Tricuspid Regurgitation: The TRILUMINATE Pivotal Randomized Controlled Trial. Circulation, 2025.PMID 40159089
14. [14]Donal E, et al. Transcatheter Edge-to-Edge Repair for Severe Isolated Tricuspid Regurgitation: The Tri.Fr Randomized Clinical Trial. JAMA, 2025.PMID 39602173
15. [15]Hahn RT, et al. Transcatheter Valve Replacement in Severe Tricuspid Regurgitation. N Engl J Med, 2025.PMID 39475399
16. [16]Hausleiter J, et al. Tricuspid-Valve Intervention in Heart Failure. N Engl J Med, 2026.PMID 42670975
17. [17]Gammie JS, et al. Concomitant Tricuspid Repair in Patients with Degenerative Mitral Regurgitation. N Engl J Med, 2022.PMID 34767705
18. [18]Chong A, et al. 2024 CSANZ Position Statement on Indications, Assessment and Monitoring of Structural and Valvular Heart Disease With Transthoracic Echocardiography in Adults. Heart Lung Circ, 2024.PMID 38749800
19. [19]De Backer J, et al. 2025 ESC Guidelines for the management of cardiovascular disease and pregnancy. Eur Heart J, 2025.PMID 40878294