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............................................................................................................................................................................. dilatation, along with RV and right atrium dimensions, as well as RV function should be measured, owing to their prognostic relevance.398

In experienced laboratories, RV strain27 and/or 3D measurements of RV volumes399,400 may be considered to overcome the existing limitations of conventional RV function indices.102 When available, CMR is the preferred method to assess the RV400 due to its high accuracy and reproducibility.401 Echocardiographic evaluation of tricuspid regurgitation severity is based on an integrative approach considering multiple qualitative and quantitative parameters (Table 9). Due to the non-circular and nonplanar shape of the regurgitant orifice, biplane vena contracta width should be considered in addition to the conventional 2D measurement.402 Similarly, underestimation of tricuspid regurgitation severity by the PISA method may occur.403 In case of inconsistent findings, the 3D vena contracta area may be evaluated, although diverging cut-offs have been reported.402,404406 Recently, a new grading scheme including two additional grades (‘massive’ and ‘torrential’) has been proposed407 and used in clinical studies on transcatheter interventions.408,409 Studies showed an incremental prognostic value of the two additional grades (massive and torrential) in terms of mortality and rehospitalization for heart failure in patients with advanced disease.410412 Alternatively, calculation of the tricuspid regurgitant volume by CMR using RV volumetry may be helpful. Importantly, estimation of pulmonary pressures using Doppler gradient may be impossible or might underestimate the severity of pulmonary hypertension in the presence of severe tricuspid regurgitation, justifying cardiac catheterization to evaluate pulmonary vascular resistances.413 8.2 Indications for intervention

Severe tricuspid regurgitation is associated with impaired survival389,414416 and worsening heart failure.397,417 In clinical practice, tricuspid valve interventions are underused and often initiated too late.418420 Appropriate timing of intervention is crucial to avoid irreversible RV damage and organ failure with subsequent increased surgical risk421,422 (see table of recommendations on indications for intervention in tricuspid valve disease in section 9 and Figure 8). Surgery is recommended in symptomatic patients with severe primary tricuspid regurgitation. In selected asymptomatic or mildly symptomatic patients who are appropriate for surgery, an intervention should also be considered when RV dilatation or declining RV function is observed. However, exact thresholds have not yet been defined. According to observational data, tricuspid valve repair should be performed liberally during left-sided surgery in patients with secondary tricuspid regurgitation. Indeed, it does not increase operative risk, but promotes reverse remodelling of the RV and improves functional status when annular dilatation is present, even in the absence of severe tricuspid regurgitation.423427 The benefit of surgical correction of isolated secondary tricuspid regurgitation compared to medical treatment is not well established428 and the procedure has a non-negligible risk of periprocedural mortality and morbidity when patients present late.429432 However, in carefully selected candidates, surgery can be performed safely with good longterm survival.418,433 It should therefore be considered early in selected symptomatic patients appropriate for surgery, as well as in those with no or mild symptoms, RV dilatation and severe tricuspid regurgitation. Although a tricuspid annular pulmonary systolic excursion (TAPSE) <17 mm has been associated with worse prognosis in patients with secondary tricuspid regurgitation,398,434 thresholds for severe RV dysfunction making intervention futile have not yet been defined. Reoperation on the tricuspid valve in new-onset or worsening secondary tricuspid regurgitation after left-sided surgery carries a high procedural risk, possibly due to late referral and subsequent poor clinical condition.435 To improve prognosis, treatment of severe tricuspid regurgitation in this challenging scenario should be considered even in asymptomatic patients if there are signs of RV dilatation or decline in RV function (after exclusion of left-sided valve dysfunction, severe RV or LV dysfunction and severe pulmonary vascular disease/ hypertension). Whenever possible, annuloplasty with prosthetic rings is preferable to valve replacement,423,430,436 which should only be considered when the tricuspid valve leaflets are tethered and the annulus severely dilated. In presence of a cardiac implantable electronic device lead, the technique used should be adapted to the patient’s condition and the surgeon’s experience.437 TTVI are under clinical development. Early registry and study data demonstrated the feasibility to reduce tricuspid regurgitation using various systems, enabling either leaflet approximation,408,438440 direct annuloplasty,409,441 or valve replacement,442444 with subsequent symptomatic and haemodynamic improvement.445,446 In a propensity-score-matched study comparing medical treatment to TTVI, all-cause mortality and rehospitalizations at 1 year were lower among the patients who received the interventional treatment.447 Several RCTs will investigate the efficacy of TTVI against medical treatment.

Table 9 Echocardiographic criteria for grading severity of tricuspid regurgitation

Qualitative Tricuspid valve morphology Abnormal/flail Colour flow regurgitant jet Very large central jet or eccentric

wall impinging jeta

CW signal of regurgitant jet Dense/triangular with early peaking Semiquantitative Vena contracta width (mm) >7a,b PISA radius (mm) >9c Hepatic vein flowc Systolic flow reversal Tricuspid inflow E-wave dominant >_1m/sd Quantitative EROA (mm2) >_40 Regurgitant volume (mL/beat) >_45 Enlargement of cardiac chambers/vessels RV, RA, inferior vena cava CW = continuous wave; EROA= effective regurgitant orifice area; PISA = proximal isovelocity surface area; RA= right atrium/right atrial; RV= right ventricle/right ventricular; TR = tricuspid regurgitation. aAt a Nyquist limit of 5060 cm/s. bPreferably biplane. cBaseline Nyquist limit shift of 28 cm/s. dIn the absence of other causes of elevated RA pressure. ESC/EACTS 2021 Downloaded from academic.oup.com/eurheartj/article/43/7/561/6358470 by guest on 07 October 2026