Tricuspid regurgitation is a form of heart valve disease where the tricuspid valve does not close tightly, allowing blood to leak backward from the right ventricle into the right atrium. To understand this, it is essential to first understand the path of blood through the right side of the heart.

1. Oxygen-poor blood returns from the body and collects in the heart’s upper right chamber, the right atrium.
2. The right atrium pumps this blood through the tricuspid valve into the heart’s lower right chamber, the right ventricle.
3. The powerful right ventricle then contracts to pump the blood forward, out through the pulmonary valve and into the lungs to pick up oxygen.

The tricuspid valve is a remarkable structure with three thin but strong flaps of tissue called leaflets. Its job is to act as a perfect one-way door. It swings open to allow blood to pass from the atrium to the ventricle, and then it must snap shut and seal tightly when the ventricle contracts to prevent any blood from flowing backward.

A helpful analogy is to think of the heart chambers as a series of rooms connected by powerful one-way doors. The tricuspid valve is the door between the main receiving hall (right atrium) and the first pumping chamber (right ventricle).

• In a healthy heart, this door slams shut, creating a perfect seal.
• In tricuspid regurgitation, this door is faulty and does not seal properly when it closes.
• As a result, every time the right ventricle pumps forward to the lungs, a significant amount of blood leaks backward through the gaps in the faulty door, back into the receiving hall. This backflow creates a “traffic jam” of blood, leading to an increase in volume and pressure in the right atrium and in the major veins throughout the body.

In my experience, many patients don’t realize they have tricuspid regurgitation until it’s found during an echocardiogram for another issue because it often progresses silently.

The causes of tricuspid regurgitation are broadly divided into two main categories, and it is very important to understand the difference between them.

1. Functional or Secondary Tricuspid Regurgitation

This is by far the most common cause, accounting for over 90% of all significant cases of TR. In secondary TR, the tricuspid valve leaflets themselves are structurally normal and healthy. The problem is not with the valve itself, but with the heart chambers around it.

Secondary TR is caused by the dilation (enlargement) of the right ventricle. When the right ventricle becomes enlarged and stretched out, it also stretches the frame, or annulus, in which the tricuspid valve sits. This stretching pulls healthy valve flyers apart. Now, even though the leaflets are normal, they are too far apart to meet in the middle and form a tight seal when the valve closes.

Any condition that causes right ventricular enlargement or high pressures on the right side of the heart can lead to secondary TR. Common causes include:

• Left-Sided Heart Disease: Problems on the left side of the heart, such as mitral valve disease or left-sided heart failure, are a leading cause. They cause blood to back up into the lungs, increasing pressure and eventually straining and enlarging the right side of the heart.
• Pulmonary Hypertension: High blood pressure in the arteries of the lungs from any cause puts immense strain on the right ventricle, causing it to dilate.
• Chronic Lung Disease: Conditions like severe COPD can lead to pulmonary hypertension.
• Congenital Heart Defects: Some birth defects can put pressure on the right ventricle.

2. Primary or Organic Tricuspid Regurgitation

This form is much less common. In primary TR, the problem lies with the valve leaflets themselves, which are damaged, malformed, or unable to function properly. Common causes of primary TR include:

• Infective Endocarditis: An infection of the heart valve. This is particularly common in individuals who use intravenous drugs, as bacteria can be introduced into the bloodstream and seed the tricuspid valve.
• Rheumatic Heart Disease: A complication of untreated strep throat, rheumatic fever can cause permanent scarring and damage to the heart valves, including the tricuspid valve.
• Congenital Defects: A person can be born with a malformed tricuspid valve. The most well-known of these is Ebstein’s anomaly, where the valve is malformed and displaced downward into the right ventricle.
• Chest Trauma: A severe blow to the chest can directly damage the valve leaflets or the chords that support them.
• Carcinoid Syndrome: A rare condition where a tumor produces hormones that can cause fibrous deposits to form on the heart valves.

Clinically, I’ve most often seen tricuspid regurgitation result from pulmonary hypertension or long-standing left-sided heart disease that stretches the valve over time.

A person develops significant tricuspid regurgitation due to another underlying medical condition. The risk factors for TR are therefore the risk factors for these other diseases.

You are at a higher risk of developing significant TR if you have:

• Any form of left-sided heart failure or valve disease.
• Pulmonary hypertension from any cause.
• Chronic obstructive pulmonary disease (COPD).
• A history of infective endocarditis or rheumatic fever.
• Been born with a congenital heart defect affecting the right side of the heart.

Patients often ask if it’s something they were born with. I explain that while congenital defects can play a role, most cases are acquired due to pressure overload or heart strain.

Mild to moderate tricuspid regurgitation is often completely asymptomatic. Symptoms usually develop only when regurgitation becomes severe. Severe TR signs and symptoms are the classic signs of right-sided heart failure.

The most common signs and symptoms include:

• Peripheral Edema: Swelling due to fluid retention in the feet, ankles, and legs.
• Ascites: A buildup of fluid in the abdominal cavity, causing the abdomen to swell and feel full.
• Jugular Venous Distension (JVD): The jugular veins in the neck become visibly swollen and may be seen pulsating.
• Fatigue and Weakness: A decreased ability to exercise or perform daily activities.
• A Pulsating Sensation in the Neck.
• An Enlarged and Tender Liver (Hepatomegaly): The congestion of blood can cause the liver to swell, leading to discomfort or pain in the upper right side of the abdomen.
• A fluttering sensation in the chest (palpitations), sometimes from associated atrial fibrillation.

Patients often describe vague symptoms like fatigue or swelling in their legs, and many are surprised to learn it’s connected to a problem with a heart valve.

The diagnosis of TR is often first suspected during a physical examination and is confirmed with an ultrasound of the heart.

• Physical Examination: When listening to the heart with a stethoscope, a doctor may hear a characteristic heart murmur. This murmur, known as a holosystolic murmur, is caused by the sound of blood leaking backward through the valve during the entire contraction phase of the ventricle. The doctor may also observe the swollen neck veins or leg edema.
• Echocardiogram (Echo): This is the gold standard and definitive test for diagnosing and assessing tricuspid regurgitation. An echocardiogram is a non-invasive ultrasound of the heart. It allows a cardiologist to:
  • Directly visualize the structure and movement of the tricuspid valve leaflets.
  • Use color Doppler imaging to see the jet of blood leaking backward across the valve.
  • Quantify the severity of the regurgitation and grade it as mild, moderate, or severe.
  • Assess the size and function of the right atrium and right ventricle.
  • Measure pulmonary artery pressure to look for pulmonary hypertension.
• Other Tests: An electrocardiogram (ECG) and a chest X-ray may also be performed to look for signs of right-sided heart enlargement.

In my experience, the condition is typically diagnosed with an echocardiogram, often while evaluating unexplained swelling, murmurs, or right-sided heart failure signs.

The treatment for tricuspid regurgitation depends entirely on its severity and, most importantly, on its underlying cause.

1. Treatment of Mild TR

Trace, mild, and even moderate TR that is causing no symptoms typically requires no specific treatment. Your doctor will recommend periodic follow-up with an echocardiogram to monitor the condition over time.

2. Treating the Underlying Cause

For secondary TR, the most important part of management is to treat the underlying condition that is causing the right ventricle to fail. This may include:

• Using medications to manage left-sided heart failure.
• Using specific therapies to treat pulmonary hypertension.
• Managing chronic lung disease. If the underlying problem can be successfully treated, the right ventricle may decrease in size, which can lessen the severity of the tricuspid regurgitation.

3. Medical Management of Symptoms

For patients with severe TR who have symptoms of fluid overload, diuretics (“water pills”) are the cornerstone of medical therapy. These medications, such as furosemide and spironolactone, help the kidneys excrete excess salt and water, which reduces the swelling in the legs and abdomen and relieves congestion.

4. Surgical Treatment

Surgery is generally reserved for patients with severe, symptomatic tricuspid regurgitation. The decision to proceed with surgery is a complex one made by a multidisciplinary heart team.

• Timing: Tricuspid valve surgery is often performed at the same time as another necessary heart operation, such as a mitral or aortic valve surgery.
• Surgical Options:
  • Tricuspid Valve Repair: The most common repair technique is an annuloplasty, where a rigid or flexible ring is sewn around the base of the valve.
  • Tricuspid Valve Replacement: If the valve leaflets themselves are too damaged to be repaired (e.g., from endocarditis or severe rheumatic disease), the entire valve will be replaced with a prosthetic valve.

In recent years, several less invasive, catheter-based techniques for repairing or replacing the tricuspid valve have been developed and are currently being studied in clinical trials.

I’ve found that managing the underlying cause, like pulmonary hypertension or fluid overload, is the first step, surgery is usually reserved for severe, symptomatic cases.

Tricuspid regurgitation is a common condition where the heart’s right-sided tricuspid valve fails to close properly, allowing blood to leak backward. While a minor leak is a frequent and harmless finding, severe TR is a serious condition that is most often a consequence of other underlying heart or lung diseases. It leads to symptoms of right-sided heart failure, such as swelling in the legs and abdomen. The cornerstone of management is to treat the root cause of the problem and to use diuretic medications to control fluid buildup. For those with severe, symptomatic disease, surgical repair or replacement of the valve can offer significant relief and improve long-term outcomes. In my experience, early recognition and management of tricuspid regurgitation can help prevent progression to debilitating right heart failure.

American Heart Association. (n.d.). Problem: Tricuspid Regurgitation. Retrieved from https://www.heart.org/en/health-topics/heart-valve-problems-and-disease/heart-valve-problems-and-causes/problem-tricuspid-regurgitation

Mayo Clinic. (2024). Tricuspid valve regurgitation. Retrieved from https://www.mayoclinic.org/diseases-conditions/tricuspid-valve-regurgitation/symptoms-causes/syc-20350262

The Cleveland Clinic. (2021). Tricuspid Regurgitation. Retrieved from https://my.clevelandclinic.org/health/diseases/21626-tricuspid-regurgitation