Tricuspid Regurgitation Treatment: A Surgeon's Guide to Your Options in 2025

Why Tricuspid Regurgitation Has Been the "Forgotten" Valve Problem

For decades, the tricuspid valve received far less attention than the aortic or mitral valve. Many cardiologists and surgeons operated under the assumption that tricuspid regurgitation (TR) would improve on its own once the left-sided valve problem was fixed. In some cases that proved true. In many others, it did not — and patients were left dealing with progressive right heart failure, swollen legs, abdominal distension, and a significantly diminished quality of life.

We now know that severe tricuspid regurgitation is not a benign condition. Studies published in the Journal of the American College of Cardiology have shown that moderate-to-severe TR is associated with increased mortality independent of left ventricular function or pulmonary artery pressure. A landmark 2004 study by Nath et al. demonstrated that even moderate TR was linked to reduced survival, regardless of ejection fraction. The message is clear: this valve matters, and waiting too long to address it carries real consequences.

If you or a family member has been told you have significant tricuspid regurgitation, this article will walk you through what that means, when tricuspid valve surgery becomes necessary, and what the current TR repair options look like — including newer, less invasive approaches.

Understanding Tricuspid Regurgitation: What Is Actually Happening

The tricuspid valve sits between the right atrium and the right ventricle. Its job is straightforward: allow blood to flow forward into the right ventricle and then out to the lungs, while preventing it from leaking backward. When the valve fails to close properly, blood regurgitates — flows backward — into the right atrium with every heartbeat.

Primary vs. Secondary TR: The Distinction That Drives Treatment

Understanding the cause of your tricuspid regurgitation is essential because it directly determines the best tricuspid regurgitation treatment approach.

• Primary (organic) TR: The valve leaflets themselves are damaged. This can result from endocarditis (infection), rheumatic heart disease, carcinoid syndrome, trauma, or a congenital abnormality like Ebstein's anomaly. Pacemaker and defibrillator leads that cross the tricuspid valve can also cause primary TR by interfering with leaflet movement. Primary TR accounts for roughly 10-15% of cases requiring intervention.
• Secondary (functional) TR: The valve leaflets are structurally normal, but the valve ring (annulus) has dilated — stretched out — because of right ventricular enlargement or elevated pressures in the pulmonary arteries. This is by far the more common scenario, often resulting from left-sided heart valve disease, atrial fibrillation, or heart failure. The valve simply cannot close properly because the opening has become too large for the leaflets to cover.

This distinction matters because secondary TR may respond to annuloplasty (tightening the ring), while primary TR with destroyed leaflets may require valve replacement. Your surgical team needs accurate imaging — typically a comprehensive echocardiogram and sometimes cardiac MRI — to make this determination.

When Does Tricuspid Valve Surgery Become Necessary?

The 2020 ACC/AHA guidelines for valvular heart disease provide a framework for when surgical intervention should be considered. Here is what I tell patients in my own practice:

Strong Indications for Tricuspid Valve Surgery

• Severe TR with symptoms: If you have significant leg swelling, ascites (fluid in the abdomen), fatigue, shortness of breath, or exercise intolerance that is attributable to your tricuspid valve, surgery should be discussed. These symptoms indicate right heart failure, which will generally worsen without intervention.
• Concurrent left-sided valve surgery: According to ACC/AHA guidelines, tricuspid valve repair is recommended at the time of left-sided valve surgery when severe TR is present (Class I indication). Even when TR is only moderate, or when the tricuspid annulus is significantly dilated (greater than 40 mm or greater than 21 mm/m² indexed to body surface area), concurrent tricuspid annuloplasty should be strongly considered (Class IIa indication). Failing to address the tricuspid valve during initial left-sided surgery is one of the most common reasons patients end up needing a riskier reoperation later.
• Progressive right ventricular dilation or dysfunction: Even without severe symptoms, if imaging shows the right ventricle is enlarging or weakening, this is a signal that the volume overload from TR is taking a toll. Intervening before irreversible right ventricular damage occurs is a core principle of modern tricuspid regurgitation treatment.

The Danger of Waiting Too Long

Here is a reality I wish more patients understood: isolated tricuspid valve surgery — meaning surgery on the tricuspid valve alone, without concomitant left-sided valve work — carries a higher operative mortality than you might expect. The Society of Thoracic Surgeons (STS) database reports operative mortality rates for isolated tricuspid valve surgery ranging from 8% to over 10%, significantly higher than isolated mitral or aortic valve surgery. Much of this elevated risk stems from the fact that, historically, patients have been referred too late — after the right ventricle has failed, the liver has become congested, and the kidneys are compromised.

The earlier the intervention is considered, the better the outcomes tend to be. If your cardiologist is taking a "watch and wait" approach to your severe TR, it is worth asking specifically what criteria they are using to determine the right timing. And it may be worth getting an independent perspective. You can request a cardiac second opinion to ensure the timing is right for your specific situation.

TR Repair Options: Repair, Replacement, and Newer Approaches

When it comes to the actual procedure, there are several TR repair options available in 2025. The choice depends on the mechanism of your regurgitation, the condition of your valve leaflets, and your overall risk profile.

Tricuspid Valve Repair (Annuloplasty)

For secondary TR — where the leaflets are structurally intact but the annulus is dilated — repair with an annuloplasty ring or band is the preferred approach. The surgeon places a prosthetic ring around the tricuspid valve annulus to reduce its diameter back to a normal size, allowing the existing leaflets to close properly again.

Repair is generally preferred over replacement when feasible because it preserves the native valve, avoids the need for long-term anticoagulation (in most cases), and is associated with better long-term outcomes. Studies have consistently shown that ring annuloplasty provides more durable results than suture-based (De Vega) annuloplasty, particularly in patients with significant annular dilation.

Tricuspid Valve Replacement

When the leaflets are severely damaged, retracted, or destroyed — as can happen with endocarditis, rheumatic disease, or carcinoid — repair may not be possible, and replacement becomes necessary. Surgeons will use either a bioprosthetic (tissue) valve or a mechanical valve.

• Bioprosthetic valves are used more commonly in the tricuspid position because the lower pressures on the right side of the heart tend to be associated with longer tissue valve durability compared to the left side. They also avoid the need for lifelong warfarin anticoagulation.
• Mechanical valves are considered in younger patients or those who already require anticoagulation for other reasons (such as a mechanical mitral valve or chronic atrial fibrillation). However, mechanical valves in the tricuspid position carry a somewhat higher risk of thrombosis than in other positions, so careful anticoagulation management is essential.

Transcatheter (Catheter-Based) Tricuspid Interventions

This is the area of most rapid evolution. For patients who are considered high-risk or prohibitive-risk for open surgery, several transcatheter devices are now available or in advanced clinical trials:

• TriClip (Abbott): FDA-approved in 2023, this is an edge-to-edge repair device similar in concept to the MitraClip used for mitral regurgitation. It is delivered through a catheter in the vein and clips the tricuspid valve leaflets together to reduce regurgitation. The TRILUMINATE Pivotal trial demonstrated that TriClip reduced TR severity by at least one grade in approximately 87% of patients at one year, with improvements in quality of life and functional capacity.
• EVOQUE (Edwards Lifesciences): FDA-approved in early 2024, this is a transcatheter tricuspid valve replacement system. It is designed for patients with severe TR who may not be candidates for repair.
• Other devices including annuloplasty systems (Cardioband) and additional replacement valves are in various stages of investigation.

It is important to set realistic expectations. Transcatheter options are not a simple fix for everyone. Patient selection is critical — outcomes depend heavily on anatomy, the degree of right ventricular dysfunction, and the mechanism of TR. These procedures should be performed at experienced centers with dedicated structural heart teams.

How to Evaluate Your Options and Make a Confident Decision

If you have been diagnosed with significant tricuspid regurgitation, here is what I recommend:

• Get a comprehensive echocardiogram — and ideally a transesophageal echo (TEE) — to clearly define the mechanism and severity of your TR. The grading of TR severity (mild, moderate, severe, torrential) directly impacts whether and when intervention is appropriate.
• Understand your risk profile. The STS risk score and EuroSCORE II are used by surgical teams to estimate operative risk. You can explore what these scores mean using our free cardiac surgery risk calculator. Knowing your estimated risk helps you weigh the benefit of intervention against the risk of the procedure itself.
• Ask about all available options. Not every center offers transcatheter tricuspid interventions. If you are high-risk for open surgery, ask whether a catheter-based approach has been considered and whether a referral to a center with that capability is appropriate.
• Do not assume "watch and wait" is always right. Serial monitoring is appropriate for mild-to-moderate TR without symptoms or right ventricular changes. But for severe TR, prolonged observation can allow irreversible damage to the right ventricle, liver, and kidneys. Push for a clear treatment timeline and defined criteria for intervention.
• Seek a second opinion if anything is unclear. Tricuspid valve disease management is evolving rapidly. What was standard practice even three to four years ago may not reflect the best options available today. A fresh set of eyes — particularly from a surgeon who operates on these valves — can be invaluable.

I frequently review cases where the tricuspid valve was under-addressed during initial left-sided valve surgery, or where patients with severe TR have been told to "live with it" without a thorough discussion of intervention. These are exactly the situations where an independent review of your imaging, your hemodynamics, and your clinical picture can change the plan — and potentially your outcome.

The Bottom Line on Tricuspid Regurgitation Treatment

Tricuspid regurgitation is no longer the forgotten valve disease. We have better diagnostic tools, clearer guidelines for intervention, and a growing array of surgical and transcatheter options. But the timing of treatment remains critical. Right heart failure that has been allowed to progress unchecked is much harder to reverse, and operative risk climbs as organ function deteriorates.

Whether you are facing a decision about concurrent tricuspid repair during left-sided valve surgery, isolated tricuspid valve surgery for progressive TR, or wondering whether a newer catheter-based approach might be right for you — these are decisions that deserve careful, expert analysis.

If you are facing a decision about tricuspid regurgitation treatment, a WhiteGloveMD second opinion can help. Our AI-powered review process, led by a board-certified cardiovascular surgeon, analyzes your imaging, risk scores, and clinical data to provide a clear, evidence-based assessment of your options — including whether the current plan is the right one. You deserve to make this decision with confidence.