Why Tricuspid Regurgitation Was Called the "Forgotten" Valve Disease
For decades, the tricuspid valve received far less attention than the aortic or mitral valves. In medical training, we were taught that tricuspid regurgitation (TR) would often "take care of itself" once the left-sided valve problem was fixed. That thinking has changed significantly — and for good reason.
We now know that moderate or severe tricuspid regurgitation, left untreated, is associated with reduced survival. A landmark study published in the Journal of the American College of Cardiology found that severe TR is independently linked to increased mortality, regardless of left ventricular function or pulmonary artery pressure. In other words, this valve matters — and ignoring it can cost patients years of life.
If you or a family member has been diagnosed with tricuspid regurgitation and told that surgery might be needed, this article will walk you through what that means, what the options are, and what questions you should be asking before making a decision.
Understanding Tricuspid Regurgitation: What Is Actually Happening?
The tricuspid valve sits between the right atrium and the right ventricle — the two chambers on the right side of your heart. Its job is to allow blood to flow forward into the right ventricle and then out to the lungs, while preventing it from leaking backward.
When the valve doesn't close properly, blood flows in the wrong direction with each heartbeat. This backward flow is called tricuspid regurgitation, or TR. Over time, this extra volume overloads the right side of the heart, causing the right atrium and ventricle to enlarge. Eventually, the heart can no longer compensate, and patients develop symptoms of right-sided heart failure: swelling in the legs and abdomen, fatigue, shortness of breath, and a general decline in functional capacity.
Primary vs. Secondary TR
Understanding the cause of your TR is essential because it directly affects which tricuspid regurgitation treatment strategy makes sense for you.
- Primary (organic) TR: The valve leaflets themselves are damaged — from infection (endocarditis), trauma, carcinoid disease, radiation, or a congenital abnormality like Ebstein's anomaly. This accounts for roughly 10-15% of significant TR cases.
- Secondary (functional) TR: The valve leaflets are structurally normal, but the annulus (the ring the leaflets attach to) has dilated due to right ventricular enlargement, pulmonary hypertension, left-sided heart disease, or atrial fibrillation. This is by far the more common scenario, representing 85-90% of cases seen in clinical practice.
Many patients with secondary TR also have mitral valve disease or have undergone prior left-sided valve surgery. If you have been told your TR is "functional," that does not mean it is unimportant. It means the underlying cause needs to be addressed alongside the valve itself.
When Is Tricuspid Valve Surgery Recommended?
According to the 2020 ACC/AHA guidelines for the management of valvular heart disease, tricuspid valve surgery is recommended in the following situations:
- Severe TR with symptoms (leg swelling, ascites, fatigue, exercise intolerance) that are not adequately controlled with diuretics and medical therapy.
- Severe TR at the time of left-sided valve surgery. If you are already having mitral or aortic valve surgery, addressing significant TR at the same time is a Class I recommendation — meaning the evidence strongly supports it.
- Progressive right ventricular dilation or dysfunction even in the absence of severe symptoms, particularly if the TR is worsening over time.
- Moderate TR with a dilated tricuspid annulus (≥40 mm or >21 mm/m²) at the time of left-sided surgery. The guidelines recognize that even moderate TR is likely to progress if the annulus is already stretched, so repairing it while the chest is open makes sense.
The most common mistake I see in practice is waiting too long. By the time a patient develops irreversible right ventricular dysfunction, severe organ congestion, or significant liver or kidney impairment, the surgical risk goes up and the benefit goes down. Timing matters.
If you have been told your TR is "not bad enough" for surgery, or if you are unsure whether the timing is right, I would encourage you to get a second opinion from a cardiac surgeon who regularly operates on this valve. The perspective of an experienced surgeon can be very different from a general assessment.
TR Repair Options: Repair vs. Replacement and Newer Approaches
Once the decision is made that the tricuspid valve needs to be addressed surgically, the next question is how. There are several TR repair options available, and the best choice depends on the anatomy, the cause of the regurgitation, and the patient's overall condition.
Tricuspid Valve Repair
Whenever possible, repair is preferred over replacement. The most common repair technique is ring annuloplasty, in which a rigid or semi-rigid ring is sewn around the dilated annulus to restore it to a more normal size and shape. This allows the existing leaflets to come together (coapt) properly and stop the leak.
Studies show that ring annuloplasty has better durability than older techniques such as the De Vega suture annuloplasty, particularly in patients with severely dilated annuli. In experienced hands, tricuspid repair can be performed with low operative mortality — often in the range of 2-5% when combined with left-sided valve surgery, and even lower when performed in isolation in appropriate candidates.
Additional repair techniques may be used depending on the anatomy:
- Leaflet augmentation or patching for damaged or retracted leaflets
- Chordal repair or replacement for prolapsing leaflets
- Edge-to-edge (clover) technique in select cases
Tricuspid Valve Replacement
When the valve leaflets are too damaged, or when the anatomy is not suitable for a durable repair, replacement is necessary. This involves removing the diseased valve and implanting either a bioprosthetic (tissue) or mechanical valve.
The choice between tissue and mechanical prostheses in the tricuspid position involves specific considerations. Bioprosthetic valves in the tricuspid position tend to have reasonable durability — often 10-15 years or more — because the pressures on the right side of the heart are lower than on the left. Mechanical valves last longer but require lifelong blood thinners (warfarin) and carry a somewhat higher risk of valve thrombosis in the tricuspid position compared to the aortic or mitral positions.
For most patients, a bioprosthetic valve is the preferred choice for tricuspid replacement, unless there is another compelling reason to be on warfarin (such as a mechanical valve already in another position).
Transcatheter (Catheter-Based) Tricuspid Interventions
This is an area of active development and genuine excitement. Several transcatheter devices are either FDA-approved or in advanced clinical trials for treating TR without open-heart surgery. The most prominent include:
- TriClip (Abbott): A transcatheter edge-to-edge repair device, similar in concept to the MitraClip used for mitral regurgitation. It was FDA-approved in 2023 based on the TRILUMINATE trial, which showed significant reduction in TR severity compared to medical therapy alone.
- EVOQUE (Edwards Lifesciences): A transcatheter tricuspid valve replacement system that received FDA approval in 2024, offering an option for patients who are not candidates for repair.
- Other devices in various stages of clinical investigation, including annuloplasty systems and heterotopic caval valve implants.
These options are particularly relevant for patients who are high-risk for open surgery — those with prior cardiac surgery, advanced age, frailty, or significant comorbidities. The data is still maturing, and long-term outcomes beyond 2-3 years are not yet available for most of these technologies. But for the right patient, transcatheter approaches can provide meaningful symptom relief and improved quality of life.
Choosing between open surgical repair, surgical replacement, and transcatheter intervention is exactly the kind of decision where a thorough evaluation of your specific anatomy, your risk profile, and the available expertise at your center makes all the difference. Our free cardiac surgery risk calculator can give you a preliminary sense of your surgical risk, but it should be interpreted alongside a complete clinical evaluation.
What Should You Ask Before Agreeing to Tricuspid Valve Surgery?
If you are facing a recommendation for tricuspid valve surgery or a transcatheter tricuspid intervention, here are the questions I would want my own family member to ask:
- Is my TR primary or secondary? If it is secondary, is the underlying cause being adequately treated?
- What is the severity of my TR? Ask for specifics: is it moderate, severe, or torrential? Is there right ventricular dilation or dysfunction on imaging?
- Am I a candidate for repair, or will I need replacement? Repair is preferred when feasible, but the surgeon should be honest about the likelihood based on your anatomy.
- What is your experience with tricuspid valve operations? Volume matters. Tricuspid valve surgery is less commonly performed than aortic or mitral surgery, and outcomes are better at centers that do it regularly.
- Am I a candidate for a transcatheter approach? If you are high-risk for open surgery, this is an important question. Not all centers offer these newer devices.
- What happens if we wait? Sometimes watchful monitoring is appropriate. But you need to understand what the consequences of delay could be — particularly in terms of right ventricular function and the ability to repair rather than replace the valve.
Do not hesitate to ask these questions. A good surgeon will welcome them.
The Importance of Expert Evaluation in Tricuspid Regurgitation Treatment
Tricuspid valve disease is nuanced. The decision about whether and when to intervene, which technique to use, and whether open surgery or a catheter-based approach is more appropriate requires expertise that goes beyond a general cardiology assessment. I have reviewed many cases where a patient was told to "wait and watch" only to discover that the right ventricle had already begun to fail — making any subsequent intervention higher risk and less effective.
I have also seen the opposite: patients sent for surgery who would have been better served with medical optimization first, or with a transcatheter approach that was not offered at their local center.
The nuances matter, and they can only be sorted out with a careful, individualized review of your imaging, your hemodynamics, your symptoms, and your surgical risk.
If you are facing a decision about tricuspid valve surgery, tricuspid regurgitation treatment, or have been told you have significant TR and are unsure about next steps, a WhiteGloveMD second opinion can help. We provide detailed, surgeon-led reviews of your complete cardiac evaluation — including echocardiography, catheterization data, and operative recommendations — delivered in clear language so you can make an informed decision with confidence. Start your review today and know that you have a board-certified cardiac surgeon in your corner.