Decoding its trends

TVD has historically been under treatment and has received increasing recognition due to its rising prevalence among all hospitalized patients. A higher incidence of the disease has been observed in women and older age groups. Moreover, the highest AAMR occurred among the Native American populations and residents of states like Oregon, Minnesota, and Vermont, particularly in the west and rural areas. The notable rise in mortality trends between 1999 and 2023 has been associated with the increasing prevalence of diabetes, obesity, and hypertension [1, 2, 5, 8].

The gender and racial divide

There are well-documented differences in gender and race when it comes to the diagnosis, management and results associated with TVDs [23, 24]. TVDs are more frequent in female patients than male patients. Females are often diagnosed at an advanced age and hence are less likely to undergo surgical intervention. Several cross-sectional studies have also indicated that the prevalence of severe TR is more frequent in Black and Hispanic populations. Yet, they undergo far fewer surgical interventions compared to other racial groups [2]. These disparities contribute to worse clinical outcomes, including greater mortality and hospitalization rates in these populations [25]. A recent analysis from the Bronx-Valve Registry by Scotti et al. [25] revealed that Black and Hispanic patients have a higher prevalence of severe TR compared to White patients, yet were significantly less likely to undergo surgical intervention despite similar symptom severity. This under-treatment was associated with increased mortality and hospitalization rates, highlighting persistent healthcare disparities in valvular disease management.

Breaking barriers

TVDs historically presented challenges due to their diagnostic and therapeutic limitations. TR in older patients, for example, is not often diagnosed promptly, as standard echocardiographic measurements of the TV often downplay TR severity. The advancement of three-dimensional echocardiography (3DE) gives a clearer view of the heart chambers. It can also identify TR severity with better accuracy, without dependence on geometric assumptions [26, 27]. In addition to diagnostics, management of TVD has witnessed an even greater breakthrough, particularly with the development of transcatheter therapies. Surgical TV repair often results in high in-hospital mortality, mostly due to prolonged delay in treatment, but also as a result of post-surgical complications [28, 29]. However, the development of transcatheter TV intervention offers low-risk treatment and is progressively showing favorable outcomes with a marked difference in quality of life [30, 31].

Despite technical advancements and increased clinical use of 3DE, which has significantly enhanced understanding of TV anatomy and regurgitant mechanisms, its practical effectiveness is limited by the need to display volumetric datasets on two-dimensional, flat screens. This can reduce the depth perception required for full spatial appreciation of annular and leaflet geometry. Emerging modalities such as 3D printing of the TV provide promising avenues to overcome this limitation. By enabling tangible exploration of the annular architecture, 3D printed models offer the potential to refine procedural planning and improve patient-specific management strategies [32].

Where you live matters

Rheumatic TS is more common in low-income regions, while high-income countries deal more with degenerative TR, demonstrating the significant impact of socioeconomic factors on the etiology of disease [33]. Furthermore, access to novel transcatheter therapies (TriClip and LuX-Valve) is mostly available in specialized centers in high-resource settings, causing disparities in treatment [34, 35].

Role of multi-modality imaging in tricuspid valve disorders

The evaluation of TVD has evolved significantly with the increasing use of multi-modality imaging, which offers a more comprehensive understanding of anatomical and functional characteristics. Transthoracic and transesophageal echocardiography remain first-line tools, but cardiac CT and cardiac MRI are increasingly employed for annular sizing, leaflet tethering, and right ventricular assessment. This approach enables accurate grading of TR severity, identification of anatomical challenges, and personalization of therapeutic decisions. The EACVI/ESC position paper by Lancellotti et al. [36] highlights that integrated use of 2D/3D echocardiography, CT, and MRI provides additive value in guiding timing and choice of interventions in native valvular disease.

Surgery vs. minimally invasive options

Surgical TV repair or replacement has long been the standard for severe symptomatic TR, but carries high in-hospital mortality—reported as 8.8% in isolated tricuspid procedures over a decade in the U.S. National Registry [13]. Transcatheter tricuspid valve interventions (TTVIs) have emerged as viable alternatives, especially for high-risk surgical candidates. The TRILUMINATE trial demonstrated that edge-to-edge transcatheter repair led to ≥ 1 grade reduction in TR in 87% of patients, with sustained improvements in NYHA functional class and Kansas City Cardiomyopathy Questionnaire scores at 12 months [34]. Similarly, the EVOQUE and LuX-Valve replacement systems have shown favorable early outcomes, though long-term durability data remain limited [35, 37]. Newer minimally invasive surgical techniques have similar outcomes with open surgical techniques while mitigating perioperative morbidity [38]. Direct comparison of transluminal edge-to-edge repair versus beating heart surgery demonstrates nuanced patient-specific factors that are best for individuals [39].

Despite technical advances, ITVS remains high risk. Large registry data show that in-hospital mortality rates for ITVS can approach 8–10%, and major adverse events may occur in approximately 30% of patients with advanced disease [13, 40, 41]. An overview of recent clinical studies comparing surgical and transcatheter tricuspid interventions is provided in Table 2. Importantly, studies indicate that outcomes are more closely related to the severity of TR and the presence of right ventricular dysfunction than to the underlying etiology [42]. These findings highlight the importance of timely referral for intervention before irreversible right heart remodeling occurs [40–42].

Bridging the gap

Advances in imaging and transcatheter technologies have expanded the therapeutic capabilities of TVDs, but numerous challenges persist. Of special concern, the scarcity of consensual guidelines, anatomical appropriateness heterogeneity criteria, and the lack of well-individualized procedural strategies for morphologically complex valves stand out [47–49].

Differences between U.S. and European recommendations, such as transcatheter approval criteria, timing of intervention, and quantification of TR severity, emphasize the need for consistent, evidence-based recommendations. As a means to further tailor patients and inform future guidelines, additional long-term outcome studies of these novel therapies are necessary [49, 50].

Medical therapy and global guideline discrepancies in secondary tricuspid regurgitation

In patients with secondary TR, medical therapy remains the first-line approach aimed at reducing volume overload and alleviating right heart failure symptoms. Diuretics are commonly used to manage congestion, though they do not modify the underlying disease progression. Advanced heart failure therapies, including neurohormonal blockade (ACE inhibitors, ARBs, beta-blockers, aldosterone antagonists), may be beneficial in selected patients with left-sided heart failure contributing to TR. However, no randomized trials have evaluated pharmacologic therapies specifically for TR.

Notably, discrepancies exist between U.S. and European guidelines regarding timing and indications for surgical or transcatheter interventions in TR. The 2020 ACC/AHA guidelines recommend surgical treatment primarily in patients undergoing LSVS with severe TR (Class I) or in selected symptomatic patients with isolated severe TR and right-sided dysfunction (Class IIa). Conversely, the 2021 ESC/EACTS guidelines offer earlier consideration for intervention in patients with progressive TR, even in the absence of left-sided pathology, especially when right ventricular dilation is evident. This divergence reflects regional differences in interpreting evidence and risk thresholds, and underscores the need for individualized treatment planning based on anatomy, etiology, and comorbid burden [49, 50].