Tricuspid regurgitation and stenosis — structured viva

Stem

Practice viva. The examiner asks how you classify and assess tricuspid regurgitation, when you operate on it, what the transcatheter trials showed, and how leads and endocarditis change the plan.^[1][9]

Branch A — Classification and work-up

Examiner: A 76-year-old woman with permanent AF has severe TR. How do you work out what kind of TR it is and how severe it is?^[1]

Strong answer:

• Only 8%–10% of TR has clear anatomical abnormality of the apparatus (primary TR); in secondary TR the leaflets are structurally normal and regurgitation comes from annular dilatation and/or leaflet tethering (ESC/EACTS 2025).^[1]
• Two secondary phenotypes have been proposed: atrial, mainly due to AF, with marked RA and annular dilatation, no significant tethering and preserved RV size and function, pulmonary pressure and LV function; and ventricular, from annular dilatation and leaflet tethering due to left-sided ventricular or valvular disease (post-capillary PH), pre-capillary PH or primary RV cardiomyopathy or ischaemia (also after left-sided valve surgery).^[1]
• With a CIED, the work-up should clarify whether the lead is the cause (CIED-related TR) or incidental (CIED-associated TR).^[1]
• Severity should ideally be assessed in euvolaemia with optimised pulmonary and systemic pressures, integrating multiple parameters.^[1]
• ACC/AHA 2020 Stage C or D TR has a central jet ≥50% RA, vena contracta ≥0.7 cm, ERO ≥0.40 cm², regurgitant volume ≥45 mL, a dense triangular CW signal and hepatic vein systolic flow reversal.^[2]

Follow-up: Her TTE estimates the PASP at 30 mmHg. Is that enough before intervention?^[1]

• No: echo often underestimates pulmonary pressures in severe TR, and ESC/EACTS 2025 says right heart catheterisation is recommended in all candidates for an intervention.^[1]
• ESC/ERS 2022 recommends RHC in severe TR, with or without left heart disease, before surgical or interventional repair (Class I, Level C).^[6]
• ACC/AHA 2020 adds that thermodilution cardiac output may be inaccurate with severe TR, so a Fick output should be used for the resistance calculation.^[2]

Branch B — Who goes to surgery

Examiner: Tell me the ESC/EACTS 2025 rows for isolated severe TR, and how ACC/AHA 2020 differs.^[1][3]

Strong answer:

• A multidisciplinary Heart Team evaluation of aetiology, disease stage, operative risk and likelihood of recovery is recommended before any intervention (Class I, Level C).^[1]
• TV surgery is recommended in symptomatic severe primary TR without severe RV dysfunction or severe PH (Class I, Level C), and should be considered in asymptomatic severe primary TR with RV dilatation or deterioration, without severe LV/RV dysfunction or severe PH (Class IIa, Level C).^[1]
• TV surgery should be considered in severe secondary TR that is symptomatic or has RV dilatation or deterioration, without severe LV/RV dysfunction or PH (Class IIa, Level B).^[1]
• ACC/AHA 2020 frames this by stage, and its isolated-TR rows include: in right-sided HF with severe primary TR (Stage D), isolated surgery can be beneficial to reduce symptoms and recurrent hospitalisations (COR 2a, LOE B-NR); in right-sided HF with severe isolated secondary TR from annular dilation, without pulmonary hypertension or left-sided disease, that responds poorly to medical therapy (Stage D), isolated surgery can be beneficial for the same aims (COR 2a, LOE B-NR); and in asymptomatic severe primary TR (Stage C) with progressive RV dilation or systolic dysfunction, isolated surgery may be considered (COR 2b, LOE C-LD).^[3]
• The TRI-SCORE and the STS isolated TV risk calculator include clinical and echo signs of RV dysfunction and hepatic and renal impairment and may help avoid futile intervention.^[1]

Branch C — Transcatheter therapy

Examiner: An 84-year-old at high surgical risk has symptomatic severe TR despite optimal medical therapy. What do you offer, and what is the evidence?^[1]

Strong answer:

• In high-risk patients with symptomatic severe TR despite optimal medical therapy, and in the absence of severe RV dysfunction or pre-capillary PH, transcatheter TV treatment should be considered to improve quality of life and RV remodelling (ESC/EACTS 2025, Class IIa, Level A). In the 2021 version, transcatheter treatment of symptomatic secondary severe TR could be considered in inoperable patients at a Heart Valve Centre with expertise in TV disease (Class IIb, Level C).^[1]
• TRILUMINATE (prospective trial randomising 350 patients with symptomatic severe TR 1:1 to TEER or medical therapy, 1-year hierarchical end point): win ratio 1.48 favouring TEER; death or tricuspid-valve surgery and heart failure hospitalisation did not appear to differ.^[12]
• TRISCEND II (400 patients with severe symptomatic TR, transcatheter replacement plus medical therapy versus medical therapy alone, randomised 2:1): 1-year win ratio 2.02, driven mainly by symptoms and quality of life, with severe bleeding 15.4% vs 5.3% and a new pacemaker in 17.4% vs 2.3%.^[15]
• ESC 2026 heart failure guidance notes that the three randomised trials it cites, of transcatheter treatment in severe symptomatic TR, showed a significant quality-of-life benefit with device therapy compared with conservative treatment, but no reduction in death or heart failure hospitalisation at 1-year follow-up, and that all were unblinded.^[4]
• TRIC-I-HF (360 patients with symptomatic severe TR and increased risk of heart failure events, randomised 2:1 to transcatheter repair plus medical therapy or medical therapy alone) reported freedom from death or heart failure hospitalisation through 3 years of 52.4% vs 21.0% (hazard ratio 0.40).^[16]

Branch D — Leads and endocarditis

Examiner: The patient has a pacemaker lead across the valve, and a second patient has tricuspid endocarditis. What changes?^[1][9]

Strong answer:

• ESC/EACTS 2025: transvenous lead repositioning or extraction can be considered in selected patients to improve TR or avoid lead jailing before tricuspid intervention, although efficacy is uncertain and the risk of damaging the valve is not negligible.^[1]
• ESC 2021, in a single Class IIa, Level C row for patients requiring pacing at the time of tricuspid valve surgery: transvalvular leads should be avoided and epicardial ventricular leads used; during tricuspid valve surgery, removal of pre-existing transvalvular leads should be considered and preferred over sewing in the lead between the annulus and a bioprosthesis or annuloplasty ring; and in an isolated tricuspid annuloplasty, based on an individual risk–benefit analysis, a pre-existing RV lead may be left in place without jailing it between ring and annulus. After mechanical TV replacement, a transvalvular RV lead should be avoided (Class III, Level C).^[7]
• ESC 2023: in right-sided IE on appropriate antibiotic therapy, the Class I scenarios for surgery are RV dysfunction secondary to acute severe TR non-responsive to diuretics (Level B), persistent vegetation with respiratory insufficiency requiring ventilatory support after recurrent pulmonary emboli (Level B), large residual tricuspid vegetations (>20 mm) after recurrent septic pulmonary emboli (Level C) and simultaneous involvement of left-heart structures (Level C); tricuspid repair should be considered instead of replacement when possible (Class IIa, Level B).^[9]