Tricuspid Regurgitation: The Forgotten Valve and the New Keyhole Treatments for It

Tricuspid regurgitation is a leak in the valve on the right side of the heart, between the right atrium and the right ventricle: when it does not close fully, some blood flows backwards with each beat, and while a trace of leakage is common and harmless, moderate to severe leakage can cause breathlessness, lasting tiredness and swelling of the legs and abdomen¹. For years it was called the forgotten valve, because there was little to offer people beyond water tablets. That has changed, and the first keyhole treatments designed specifically for it are now in use.

I came across it because of a reader’s email. Her mother, in her eighties, had a pacemaker, constant swollen ankles and a heart scan that mentioned “severe TR”, and the daughter wanted to know whether there was “a TAVR for that valve too”. The honest answer, it turned out, is “sort of, recently, for some people”. This guide is my attempt to set that out. For the four valves in general, start with types of heart valves.

The valve, and what goes wrong

The tricuspid valve has three leaflets that let blood pass from the right atrium into the right ventricle and then seal shut as the ventricle pumps blood towards the lungs². When the seal fails, some blood is pushed back into the atrium and the veins behind it.

Doctors divide the causes into two main groups¹. Primary tricuspid regurgitation means the leaflets themselves are damaged or abnormal, from a congenital condition such as Ebstein’s anomaly, from infection, rheumatic disease, injury, radiation or certain medicines. It is the less common form. Secondary, or functional, tricuspid regurgitation means the leaflets are structurally normal, but the right side of the heart has enlarged and stretched the ring the valve sits in, so the leaflets no longer meet.

The conditions that enlarge the right heart include failure of the left ventricle, severe mitral regurgitation, high blood pressure in the lungs, and atrial fibrillation¹. A further group is linked to atrial fibrillation, previous heart surgery, or a transvenous pacemaker or defibrillator lead that crosses the valve and stops the leaflets closing cleanly¹. That last cause was the one in my reader’s mother.

How common it is

Trace tricuspid regurgitation is extremely common on heart scans, while moderate to severe leakage affects roughly 5 to 8 in every 1,000 people in the US¹. It becomes more common with age and with the other conditions that strain the right heart.

That distinction matters, because a great many people see “tricuspid regurgitation” on an echo report and panic. A trivial or mild leak is a description, not a diagnosis of disease. The words to look for are moderate and severe, and even then what matters most is whether you have symptoms and what is causing the leak. The guide to heart valve tests and scans explains how echocardiograms grade leaks.

Symptoms

Mild tricuspid regurgitation usually causes no symptoms; moderate to severe leakage can cause breathlessness with activity, tiredness that lasts for days, and swelling in the abdomen, ankles or feet¹. A doctor may also notice a murmur or an unusually strong pulse in the neck or near the liver.

The swelling is the feature people notice most, because the leak pushes pressure back into the veins that drain the body. Tight shoes by evening, sock marks, a swollen tummy, poor appetite and early fullness are all common. Because these overlap with heart failure from other causes, lung disease and even liver or kidney problems, a scan rather than the symptoms alone makes the diagnosis.

Echocardiography is the usual test, sometimes with blood tests, a chest X-ray, an ECG or a cardiac MRI, and only rarely a catheter study¹.

Treatment: medicines and the underlying cause first

Treatment depends on the severity and the cause, and often starts with medicines to manage symptoms and treatment of whatever is driving the leak¹. Because most tricuspid regurgitation is secondary, fixing the upstream problem can sometimes reduce the leak itself.

In practice this might mean water tablets to reduce fluid and swelling, managing atrial fibrillation, treating left-sided heart failure, or dealing with a failing mitral or aortic valve. Someone with severe aortic stenosis and secondary tricuspid leakage may find the tricuspid leak improves once the aortic valve is replaced, which is one reason heart teams look at all four valves together. The 2021 European and 2020 American valve guidelines both address when the tricuspid valve should be treated, including at the time of left-sided valve surgery³⁴.

Surgery to repair or replace the tricuspid valve has long existed¹, but on its own it has been performed relatively rarely, partly because many people with severe tricuspid regurgitation are older and have other conditions that make open surgery risky. That gap is what the new catheter treatments aim to fill.

The new keyhole options

In 2024 the United States approved the first catheter treatments built for the tricuspid valve: TriClip, which clips the leaflets together, and EVOQUE, a valve replacement delivered on a catheter⁵. Both reach the heart through a vein, usually from the groin, without opening the chest.

TriClip is a transcatheter edge-to-edge repair, or TEER, the same principle as the mitral clip described in MitraClip explained. A small clip grasps the edges of two leaflets and holds them together so the valve closes better. Its approval covers people with symptomatic severe tricuspid regurgitation despite optimal medical therapy who are at intermediate or greater surgical risk, where a heart team judges the clip appropriate and likely to reduce the leak to moderate or less⁵.

The evidence behind it is the TRILUMINATE trial, which randomised 350 people with symptomatic severe tricuspid regurgitation to the clip plus medicines or medicines alone⁶. At 30 days, 87% of the clip group had leakage reduced to moderate or less, against 4.8% of the medicines group, and 98.3% were free of major adverse events⁶. Quality of life scores improved by an average of about 12 points with the clip against less than 1 point without it. But there was no apparent difference between the groups in death, tricuspid surgery or heart failure hospitalisation over the trial period⁶. In plain terms: on current evidence, the clip helps people feel and function better, and whether it helps them live longer is not yet shown.

EVOQUE replaces the valve rather than clipping it, and it was approved with a broader indication than TriClip⁵. As with TAVR, a replacement brings its own considerations, including blood thinning and the possibility of needing a pacemaker, which your heart team would discuss in detail.

Availability varies a great deal between countries and centres, and these devices are newer than TAVR, so long-term data are still being gathered.

Who decides, and what to ask

Whether a catheter treatment for the tricuspid valve makes sense is a heart team decision, made after detailed imaging, usually including a scan through the gullet (transoesophageal echocardiogram) to see whether the leaflets can be grasped³. Not every leaky valve is suitable; some gaps are too wide, and pacemaker leads can get in the way.

Questions worth taking to the cardiologist:

• How severe is the leak, and what is causing it?
• Can treating the cause, such as atrial fibrillation or another valve, reduce it?
• Am I already on the best medicines for the swelling and breathlessness?
• Would a clip or a replacement be considered for me, and is either available here?
• What would we expect it to change: symptoms, swelling, how far I can walk?
• If a pacemaker lead is involved, how does that affect the options?

The general list in questions to ask your cardiologist about TAVR translates well to the tricuspid valve too.

What happened to my reader’s mother

My reader wrote again some months later. Her mother’s heart team had reviewed her water tablets, adjusted her pacemaker settings, and referred her to a regional centre for imaging to see whether a clip might be possible. The answer, in the end, was no; the lead sat in a way that made the clip impractical. But the medicine changes alone had taken a good deal of the swelling down, and she was walking to the end of the road again.

I tell that story because it is the honest shape of this field. The new devices are a genuine advance for a valve that was ignored for decades, and for the right person they can make a real difference to daily life. They are not yet a TAVR for everyone. The first step is still to understand what is causing the leak, and to have the conversation with a team who can see all four valves at once.