This article is based on an interview with Dr Julien Dreyfus, Interventional Cardiologist at Centre Cardiologique du Nord, Saint-Denis, France, conducted for Radcliffe Cardiology at EuroPCR 2026.
Key Take-home Messages
- Tricuspid regurgitation (TR) is increasingly recognised as a major contributor to heart failure, hospitalisation and mortality.
- Earlier referral to specialist heart valve centres is essential to optimise outcomes and prevent irreversible right ventricular and end-organ damage.
- Advances in transcatheter tricuspid valve repair and replacement are expanding treatment options, making precise patient selection more important than ever.
Tricuspid Regurgitation Is No Longer the ‘Forgotten Valve’
Tricuspid regurgitation has historically been one of the most underdiagnosed and undertreated forms of valvular heart disease. However, growing evidence has established significant TR as an independent predictor of adverse clinical outcomes, including heart failure hospitalisation, reduced quality of life and increased mortality (Adamo et al., 2024; Tomasoni et al., 2026).
Speaking at EuroPCR 2026, Dr Julien Dreyfus highlighted two key factors driving rapid progress in the field.
The first is increased recognition of the burden associated with untreated TR. For many years, significant TR was often regarded as a secondary finding rather than a disease requiring active management. Today, clinicians increasingly acknowledge that TR contributes directly to worsening symptoms, progressive right heart dysfunction and poor long-term outcomes.
The second driver is the emergence of transcatheter tricuspid valve interventions. The availability of less invasive treatment options has transformed the therapeutic landscape and created new opportunities for patients who may previously have been considered unsuitable for surgery.
"TR is not a benign disease," said Dr Dreyfus. "We now have treatments that can be delivered safely and effectively, and this has fundamentally changed how we think about these patients."
As transcatheter repair and replacement technologies continue to evolve, the focus is shifting from whether patients can be treated to ensuring that they are identified and referred early enough to benefit.
Earlier Referral May Be the Biggest Unmet Need in TR Care
Despite significant advances in treatment, many patients with TR continue to be referred late in their disease journey.
According to Dr Dreyfus, delayed referral remains one of the greatest obstacles to improving outcomes. By the time many patients reach specialist centres, they have already developed substantial right ventricular remodelling, hepatic congestion, renal impairment or other manifestations of advanced right-sided heart failure.
Importantly, procedural success does not always translate into meaningful clinical benefit when intervention occurs too late. Recent consensus documents and guideline updates have increasingly emphasised the importance of referral before irreversible cardiac and end-organ damage develops (Adamo et al., 2024; Adamo et al., 2026).
Which Patients Should Be Referred for Specialist Evaluation?
A practical referral strategy can be based on TR severity, symptoms and the presence of clinical risk factors.
Patients with less than moderate TR should undergo routine clinical and echocardiographic follow-up.
Patients with severe symptomatic TR, or severe TR associated with significant right heart dilatation, should be referred directly to a specialist heart valve centre.
For patients with moderate TR or asymptomatic severe TR, clinicians should remain alert for important referral triggers, including:
- Requirement for diuretic therapy
- Previous left-sided valve intervention
- Elevated pulmonary pressures
- Atrial fibrillation
The presence of any of these factors should prompt referral for comprehensive assessment.
This approach reflects a broader shift towards proactive disease management and earlier intervention strategies designed to preserve right ventricular function and improve long-term outcomes (Tanaka et al., 2024; Adamo et al., 2026).
Multimodality Imaging Is Central to Modern TR Management
Accurate diagnosis and treatment planning increasingly depend on a multimodality imaging approach.
Transthoracic echocardiography remains the cornerstone of TR assessment and provides essential information on disease severity, valve anatomy, right ventricular function and pulmonary pressure estimates.
However, Dr Dreyfus emphasised that echocardiography alone is no longer sufficient for many patients being considered for intervention.
For those undergoing evaluation for transcatheter edge-to-edge repair (TEER), detailed anatomical assessment is necessary to determine procedural feasibility and predict the likelihood of achieving a meaningful reduction in regurgitation.
For patients being considered for transcatheter tricuspid valve replacement (TTVR), computed tomography plays a critical role in procedural planning, device sizing and anatomical suitability assessment (Sugiura et al., 2025).
Right heart catheterisation remains equally important. In patients with severe TR, echocardiography may underestimate pulmonary pressures or fail to identify clinically important haemodynamic abnormalities. Invasive assessment therefore remains the gold standard for evaluating pulmonary haemodynamics and identifying pre-capillary pulmonary hypertension.
Cardiac magnetic resonance imaging can provide additional information when uncertainty remains regarding right ventricular function, right heart remodelling or TR severity.
The growing complexity of patient assessment reflects the increasingly personalised nature of TR management.
Why Heart Team Decision-Making Matters
Patients with TR represent a highly heterogeneous population.
Differences in anatomy, disease mechanism, comorbidities and procedural risk mean treatment decisions cannot be based on a single imaging test or clinical parameter.
According to Dr Dreyfus, optimal decision-making requires input from a multidisciplinary Heart Team that may include:
- Interventional cardiologists
- Imaging specialists
- Cardiac surgeons
- Anaesthetists
- Electrophysiologists
- Heart failure specialists
- Other relevant experts
Risk assessment tools such as TRI-SCORE can support decision-making by helping clinicians estimate procedural risk and expected outcomes.
This collaborative model is increasingly reflected in contemporary guideline recommendations and specialist valve centre workflows (Adamo et al., 2026).
Transcatheter Repair Versus Replacement: Choosing the Right Strategy
The expansion of transcatheter therapies has fundamentally changed the treatment landscape for TR.
Historically, surgery represented the only definitive treatment option. Although surgical outcomes were often perceived as poor, this was largely influenced by late referral patterns and the advanced disease stage of many patients undergoing intervention.
Today, clinicians can choose between a growing range of transcatheter repair and replacement technologies.
Repair Remains the Preferred Option When Feasible
When anatomy is favourable, repair is generally considered the preferred strategy.
Available evidence suggests that patients achieve better outcomes when residual TR is reduced to moderate or less following intervention (Sugiura et al., 2025).
For this reason, transcatheter edge-to-edge repair is often selected when clinicians can confidently predict an effective and durable result.
Replacement Expands Treatment Opportunities
Not all patients have anatomy suitable for repair.
When significant residual TR is anticipated despite intervention, transcatheter valve replacement may offer a more effective solution.
The replacement field is developing rapidly, with multiple devices currently being evaluated across a wide range of patient populations. As clinical experience grows, Heart Teams are gaining more flexibility to tailor therapy according to anatomical characteristics and procedural objectives.
As Dr Dreyfus noted, the goal should not be to favour repair or replacement universally, but to select the treatment most likely to achieve a durable reduction in TR for an individual patient.
What Does the Future of TR Care Look Like?
The field of tricuspid valve intervention is evolving at remarkable speed.
Technological innovation continues to expand the range of available therapies, while growing awareness among cardiologists is helping to bring TR into mainstream structural heart practice.
Yet the central message from Dr Dreyfus was not about devices alone.
Improving outcomes will depend on identifying patients earlier, establishing clear referral pathways and ensuring that multidisciplinary Heart Teams can match the right patient to the right treatment at the right time.
As the treatment toolbox continues to grow, earlier diagnosis and intervention may ultimately prove just as important as the next generation of transcatheter technology.
References
- Adamo M, Chioncel O, Pagnesi M, et al. (2024) Epidemiology, Pathophysiology, Diagnosis and Management of Chronic Right-sided Heart Failure and Tricuspid Regurgitation. European Journal of Heart Failure.
- Tanaka T, Vogelhuber J, Nickenig G and Praz F. (2024) Tricuspid Regurgitation: Evaluation and Risk Stratification. ESC CardioPractice.
- Sugiura A, Tanaka T, Kavsur R, et al. (2025) Tricuspid Regurgitation: Innovation, Current Landscape and Future Perspective of Transcatheter Tricuspid Valve Interventions. Journal of Cardiology.
- Adamo M, Massussi M, Ajmone Marsan N, et al. (2026) 2025 ESC/EACTS Valvular Heart Disease Guidelines: Practical Updates on Mitral and Tricuspid Regurgitation. European Heart Journal Supplements.
- Tomasoni D, Oriecuia C, Adamo M, et al. (2026) Prevalence and Prognostic Role of Untreated Moderate-to-Severe Tricuspid Regurgitation: A Systematic Review and Meta-analysis. European Journal of Heart Failure.