Dr Julien Dreyfus (Centre Cardiologique du Nord, Saint-Denis, France) discusses workflow strategies for the transcatheter treatment of tricuspid regurgitation (TR) across a broad patient population.
Recorded on-site at EuroPCR 2026, Paris.

Why are things moving so fast in the TR field?

Two factors are driving the rapid progress in the field of tricuspid regurgitation. Firstly, there is now widespread recognition that TR is not a benign condition. Until recently, many community cardiologists, interventional cardiologists and surgeons regarded TR as relatively harmless. However, numerous studies have demonstrated that significant TR is associated with poor clinical outcomes, including increased morbidity and mortality.
Secondly, we now have effective transcatheter treatment options. The availability of safe, less invasive alternatives to surgery has transformed the management of these patients and accelerated interest in the field.

When should patients be referred to heart valve centres?

Historically, patients with TR were often not referred because the condition was underestimated and there were limited treatment options available. Today, one of the major challenges is that patients are still referred too late in the disease course.
Even when transcatheter interventions are performed safely and successfully, outcomes remain poor if patients have already developed significant organ damage. Referral should therefore take place before the onset of advanced right ventricular dilatation or dysfunction, and before liver or kidney impairment develops.
A practical approach can be based on TR severity:
• Patients with less than moderate TR should undergo regular clinical and echocardiographic follow-up.
• Patients with severe TR who are symptomatic or have significant right heart dilatation should be referred directly to a heart valve centre.
• Patients with moderate TR, or severe TR without symptoms or major chamber dilatation, should be assessed for clinical red flags.
Important red flags include:
• Requirement for diuretic therapy
• Previous left-sided valve intervention
• Elevated pulmonary pressures
• Atrial fibrillation
The presence of any of these factors should prompt referral to a specialised heart valve centre.
This approach has been addressed by the PCR Tricuspid Focus Group and is reflected in recent European guidance.

What is the diagnostic pathway?

The diagnostic pathway begins with transthoracic echocardiography, which remains the cornerstone of assessment. Echocardiography is essential for evaluating TR severity, understanding valve anatomy, assessing right ventricular size and function, and estimating pulmonary pressures.
However, echocardiography alone is not sufficient. Additional investigations are often required to determine suitability for transcatheter intervention.
For patients being considered for transcatheter edge-to-edge repair, detailed imaging is necessary to assess anatomical feasibility. If repair is not suitable and replacement is being considered, computed tomography can provide important anatomical information.
Right heart catheterisation is also mandatory in many cases. Echocardiography has limitations when assessing pulmonary pressures, particularly in severe TR. Catheterisation remains the most accurate method of measuring pulmonary haemodynamics and identifying pre-capillary pulmonary hypertension, which may require specific management.
Cardiac magnetic resonance imaging (CMR) can also be valuable when there is uncertainty regarding TR severity or right ventricular size and function.
Alongside imaging, clinicians should assess patient comorbidities and calculate risk scores such as the TRI-SCORE.
All findings should then be reviewed by a multidisciplinary heart team, including interventional cardiologists, imaging specialists, cardiac surgeons, anaesthetists, electrophysiologists and other specialists as required. This collaborative approach is essential because patients with TR represent a highly heterogeneous population with diverse anatomies, comorbidities and treatment options.

What treatment options are currently available?

The treatment landscape for TR has expanded considerably. Until recently, surgery was the only available option. Surgical outcomes were often perceived as poor, largely because patients were referred at a very advanced stage of disease. When patients are referred earlier and treated before significant deterioration, surgical outcomes can be favourable.
Nevertheless, many patients with TR are elderly and at elevated surgical risk, making transcatheter therapies particularly attractive.
Current transcatheter options include both repair and replacement strategies. As with surgery, repair should generally be preferred whenever it is feasible and likely to achieve an optimal result.
Evidence suggests that patients achieve better outcomes when residual TR is reduced to moderate or less. If clinicians can reasonably predict that transcatheter edge-to-edge repair will achieve this result, repair is usually the preferred strategy. If an adequate reduction in regurgitation is unlikely, transcatheter valve replacement may be a more appropriate option.
Other technologies, including spacer-based approaches, are also available, although repair and replacement currently represent the main treatment strategies.
The field continues to evolve rapidly, with new devices and treatment options under development. This growing range of therapies provides clinicians with increasing flexibility to tailor treatment to individual patient needs.