SamDawkins Consultant Cardiologist

Tricuspid Regurgitation

Tricuspid regurgitation is a leaky tricuspid valve. The tricuspid valve sits between the right atrium and the right ventricle, and normally prevents blood flowing backwards when the right ventricle contracts. In tricuspid regurgitation the valve does not close properly, so blood leaks backwards into the right atrium and the venous system, allowing pressure to build up in the body’s veins.

What causes tricuspid regurgitation?

There are many causes. The most common is secondary (or functional) tricuspid regurgitation — the valve itself is not directly diseased but stretches because of an enlarged right ventricle, an enlarged right atrium, or persistent atrial fibrillation. Primary tricuspid regurgitation, where the valve leaflets themselves are abnormal, is less common and includes causes such as previous endocarditis, rheumatic disease, congenital abnormalities, or damage from pacemaker or defibrillator leads. Severe tricuspid regurgitation is increasingly recognised in older patients, particularly those with atrial fibrillation or long-standing left-sided heart disease.

What are the symptoms?

Mild tricuspid regurgitation rarely causes symptoms. As the leak becomes more severe, patients may develop:

  • Breathlessness on exertion
  • Fatigue and reduced exercise tolerance
  • Swelling of the ankles and legs (peripheral oedema)
  • Abdominal swelling and discomfort (ascites)
  • Liver congestion, sometimes with abnormal liver tests
  • Worsening of pre-existing atrial fibrillation

How is tricuspid regurgitation assessed?

The diagnosis is usually made on echocardiography. Severity is graded as mild, moderate, severe or torrential, based on the volume of blood leaking back across the valve.

  • Electrocardiogram (ECG) — almost always shows atrial fibrillation in patients with severe TR.
  • Transthoracic echocardiogram (TTE) — the principal test. Establishes the cause (primary or secondary), grades the leak, and assesses right ventricular size and function.
  • Transoesophageal echocardiogram (TOE) — gives high-resolution images of the valve leaflets and is used when transcatheter intervention is being considered.
  • Cardiac MRI — the most accurate test for right ventricular size and function, which is critical in deciding whether and how to intervene.
  • Cardiac CT — used to plan transcatheter procedures, particularly tricuspid valve replacement (EVOQUE) and caval valve implantation (TricValve).
  • Right heart catheterisation — used in selected patients to measure pulmonary pressures and confirm the haemodynamic impact of the leak.
  • Ambulatory ECG monitoring — when the rhythm is uncertain or AF is suspected.
  • Blood tests — particularly liver function (which can be abnormal due to congestion), kidney function and BNP.

Where treatment is being considered, additional planning tests are arranged in the structural multidisciplinary meeting.

What are the treatment options?

Mild and moderate tricuspid regurgitation usually do not need specific treatment beyond managing any underlying cause (for example controlling atrial fibrillation) and using diuretics for fluid retention.

For symptomatic severe tricuspid regurgitation, the options are:

The right choice depends on the underlying cause, the severity of the leak, the function of the right ventricle, surgical risk, and the dominant symptoms. The decision is always made in a structural valve multidisciplinary team meeting.