This review includes discussion of the mechanisms of tricuspid regurgitation (TR), the accepted indications for surgical intervention for TR, risk factors for the failure of repair, and transcatheter interventions. The following are points to remember:

1. More than 90% of TR is secondary, usually related to left-sided heart disease and/or pulmonary hypertension; with less common etiologies related to primary right ventricular (RV) disease (including RV infarction), or isolated functional TR (caused by isolated enlargement of the right atrium [RA] due to aging and/or atrial fibrillation). Primary TR is uncommon, with etiologies including rheumatic heart disease, myxomatous disease, Ebstein’s anomaly, infective endocarditis, carcinoid or infiltrative valvulopathy, or iatrogenic trauma related to implantable leads or RV biopsy.
2. Pathological TR is associated with anatomic features of tricuspid annular dilation and RV remodeling.
3. Early in the course of disease, symptoms mainly are due to pulmonary congestion (typical in early secondary TR) and central venous congestion (typical in early primary TR and later secondary TR).
4. TR severity can be assessed echocardiographically based on qualitative criteria (valve morphology, RA and RV enlargement, inferior vena cava dilation, and color-flow and continuous-wave spectral Doppler), semi-quantitative criteria (vena contracta width, hepatic vein systolic flow reversal), and quantitative criteria (regurgitant orifice area and regurgitant volume). However, the variability of TR with preload and afterload limits standard grading criteria.
5. The authors propose a grading classification for TR that integrates echocardiographic parameters (TR quantitative parameters, annular dilation, leaflet coaptation, RV remodeling and dysfunction, and RV-pulmonary artery coupling) and clinical characteristics (central venous pressure, renal and liver function, ascites, and edema).
6. Medical therapies for TR include treatment of heart failure, and when present, treatment of pulmonary hypertension.
7. Current American Heart Association (AHA)/American College of Cardiology (ACC) and European Society of Cardiology (ESC)/European Association for Cardio-Thoracic Surgery (EACTS) guidelines recommend intervention for severe symptomatic primary or secondary TR at the time of left-sided heart surgery. In addition, ESC/EACTS guidelines recommend intervention (and AHA/ACC guidelines recommend consideration for intervention) in patients with severe primary TR who remain symptomatic despite optimal medical therapy. Consideration for intervention in other patients is based on TR severity, tricuspid annular dilation, leaflet tethering, pulmonary artery pressure, and symptoms of right heart failure.
8. Surgical interventions include suture or ring tricuspid annuloplasty, and tricuspid valve (TV) replacement. Echocardiographic predictors of persistent or recurrent TR after repair include preoperative TR severity, annular diameter, advanced leaflet tethering, severe pulmonary hypertension, and reduced RV function; clinical predictors include female sex, chronic atrial fibrillation, intra-annular implanted electronic leads, renal dysfunction, and obstructive pulmonary disease; surgical factors include the use of suture annuloplasty and the use of flexible rather than rigid ring annuloplasty.
9. Transcatheter interventions are emerging as an option for symptomatic patients thought to be at high risk for surgery. Currently available devices can be classified according to the therapeutic target, including leaflet devices, annuloplasty devices, heterotopic caval valve implantation, and transcatheter valve replacement. Most devices are in early feasibility phases, and the authors note that it is not currently possible to define a proper indication for transcatheter TV intervention.
10. The following are summary recommendations for various interventions:

TV Repair

• TV repair has importance among patients with functional TR.
• Ring annuloplasty is associated with better results than suture annuloplasty.
• In the absence of predictors of failure, repair can be considered in the setting of implanted electronic lead-induced TR; but it should be accompanied by lead removal and epicardial lead implantation.
• If predictors of TR recurrence are present, techniques other than repair should be considered. In the setting of advanced leaflet tethering and RV remodeling, adjunctive repair techniques (including anterior leaflet augmentation) can be considered.

TV Replacement

• TV replacement has importance among patients with primary TR and severe leaflet pathology.
• TV replacement should be considered among patients with end stage functional TR due to a high rate of failure of TV repair.
• TV replacement should be considered among patients with implanted lead-induced TR and factors predictive of repair failure.
• Although TV replacement has been associated with a worse prognosis compared to TV repair, this might be due to differences in the respective populations.

Transcatheter Techniques

• Transcatheter TV interventions are emerging as an alternative for symptomatic patients who are at high risk for conventional surgery.
• The type of device for transcatheter TV repair (leaflet devices, annuloplasty devices) should take into consideration echocardiographic assessment of the specific etiology of TR.
• Indications for TV replacement in the surgical setting could be applied to high-risk patients for possible heterotopic caval valve implantation or transcatheter TV replacement.

Clinical Topics: Arrhythmias and Clinical EP, Cardiac Surgery, Diabetes and Cardiometabolic Disease, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, Pulmonary Hypertension and Venous Thromboembolism, Valvular Heart Disease, Atrial Fibrillation/Supraventricular Arrhythmias, Cardiac Surgery and Arrhythmias, Cardiac Surgery and Heart Failure, Cardiac Surgery and VHD, Acute Heart Failure, Pulmonary Hypertension, Interventions and Imaging, Interventions and Structural Heart Disease, Interventions and Vascular Medicine, Echocardiography/Ultrasound, Hypertension

Keywords: Ascites, Atrial Fibrillation, Carcinoid Tumor, Cardiac Surgical Procedures, Cardiology Interventions, Central Venous Pressure, Diagnostic Imaging, Dilatation, Echocardiography, Echocardiography, Doppler, Edema, Endocarditis, Heart Failure, Heart Valve Diseases, Hyperemia, Hypertension, Pulmonary, Iatrogenic Disease, Infarction, Lung Diseases, Obstructive, Rheumatic Heart Disease, Risk Factors, Tricuspid Valve Insufficiency, Vena Cava, Inferior

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