Tricuspid regurgitation: what is the real clinical impact and how often should it be treated?

Tricuspid regurgitation (TR) is a frequently occurring valvular disease in the elderly population, the aetiology is functional in the vast majority of cases, and this valvular disease has become increasingly recognised as an independent predictor of morbidity and mortality. Early diagnosis and mechanical correction of TR is essential in impacting on the natural history of this valvular condition, but this is complicated by the fact that the majority of patients are asymptomatic, despite having moderate-to-severe TR. Multi-modality imaging, in particular echocardiography, is paramount in determining the mechanism, severity, and potential treatment options of TR. Patients with symptomatic severe TR often have multiple comorbidities and present with advanced tricuspid valve and right ventricular remodelling, thus limiting the treatment and prognosis. Indeed, this is a very heterogeneous and complex group of patients, where choosing the correct treatment may be challenging especially as the majority of patients present late, when surgical intervention is often associated with significant periprocedural morbidity and mortality. This has resulted in the development of numerous percutaneous transcatheter repair and replacement devices to treat this large group of high surgical risk patients. To impact on the natural history of severe TR will require earlier diagnosis and referral for treatment, a better understanding of the different stages of disease and potential treatment options, proven safe and efficacious percutaneous options, and an evidence base for earlier surgical or percutaneous intervention of significant TR, irrespective of symptoms.