Tricuspid Regurgitation, the Once-Forgotten Valve: Current Management Options and Remaining Gaps After the 2025 European Society of Cardiology Guidelines Update

Figures

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  Fig. 1.. Historical description of tricuspid valve anatomy variability. Title pages of Historia anatomica humani corporis partes by Andreas Laurenti (1606) [15] (A), and Elementa physiologiae corporis humani by Albrecht Von Haller (1757) [16] (C); portrait of Albrecht von Haller (Bern, 1708–1777) (B); engraving og human atrioventricular valves from Haller’s Elementa physiologiae corporis humani, Volume I, Table II (D).

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  Fig. 2.. Treatment strategies for tricuspid regurgitation and key determinants of patient selection. Overview of current therapeutic options, including surgical intervention (shown in red) and transcatheter options (shown in blue): transcatheter tricuspid edge-to-edge repair (T-TEER); orthotopic transcatheter tricuspid valve replacement (TTVR); heterotopic caval valve implantation (CAVI), and transcatheter annuloplasty. Key factors influencing treatment selection are also illustrated, including frailty, EuroTR and TRIVALVE scores, pulmonary hypertension (PH), right ventricular (RV) function (e.g., TAPSE/PASP ratio), tricuspid regurgitation proportionality (e.g., EROA/RVEDD ratio), anatomical suitability and bleeding risk.

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  Fig. 3.. Transcatheter tricuspid edge-to-edge repair (T-TEER). Severe TR before (A) and after (B) TriClip implantation; TriClip device sizes (C). Schematic representation of T-TEER techniques, including triple-orifice (D) and bicuspidalization approaches (E), highlighting clip positioning relative to the anterior, septal (STL), and posterior leaflets and the tricuspid annulus. Traction of the STL leaflet provides an annuloplasty effect.

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  Fig. 4.. Orthotopic transcatheter tricuspid valve replacement (TTVR) planning with the EVOQUE device. Multiplanar CCT reconstructions of the TV apparatus and RH chambers. Upper panels show detailed assessment of the TV annulus in systole and diastole, including anteroposterior, septolateral, maximum, and minimum diameters, annular area, and perimeter, highlighting its dynamic geometry. Basal RV dimensions with virtual EVOQUE valve positioning and longitudinal views of the RH chambers (including RA height and RV depth) are also shown in diastole and systole. Pre-procedural image screening is essential for valve selection. The lower panel illustrates available EVOQUE prosthesis sizes (44–56 mm). CCT is essential for TTVR feasibility, sizing, and procedural planning.

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  Fig. 5.. Proposed late-stage tricuspid regurgitation phenotype and therapeutic window for intervention. Progressive severe TR leads to RV volume overload, adverse remodeling, pulmonary vascular disease, and systemic venous congestion. As disease advances, unfavorable hemodynamic markers—including low TR proportionality (EROA/RVEDD <0.110), impaired RV-PA coupling (TAPSE/PASP <0.406), and elevated invasive mPAP (>46 mmHg)—may identify patients with limited potential for RV reverse-remodeling after intervention. Beyond the proposed “point of no return”, multiorgan involvement (cardiorenal/cardiohepatic syndrome, cachexia, refractory ascites, and frailty) may limit the likelihood of survival benefit, although symptomatic improvement may still occur. The lower panel illustrates the proposed therapeutic window, where earlier intervention may maximize reverse remodeling and long-term outcomes. Thresholds are derived from current observational evidence and should be considered hypothesis-generating.