--- title: Tricuspid regurgitation description: What tricuspid regurgitation is, why it develops, how it is detected, which treatment approaches clinical guidelines describe and when to see a doctor urgently. type: disease aliases: - TR - tricuspid valve insufficiency sources: - tier: guideline org: esc title: 2025 ESC/EACTS Guidelines for the management of valvular heart disease year: 2025 doi: 10.1093/eurheartj/ehaf194 url: https://www.escardio.org/guidelines/clinical-practice-guidelines/all-esc-practice-guidelines/valvular-heart-disease/ - tier: guideline org: nice title: 'Heart valve disease presenting in adults: investigation and management (NG208)' year: 2021 url: https://www.nice.org.uk/guidance/ng208 - tier: reference org: msd-manuals title: Tricuspid Regurgitation year: 2025 url: https://www.msdmanuals.com/professional/cardiovascular-disorders/valvular-disorders/tricuspid-regurgitation - tier: reference org: msd-manuals title: Tricuspid Regurgitation (Consumer Version) year: 2025 url: https://www.msdmanuals.com/home/heart-and-blood-vessel-disorders/heart-valve-disorders/tricuspid-regurgitation sources_checked: 2026-10-12 review: null --- Tricuspid regurgitation (tricuspid valve insufficiency) is a condition in which the tricuspid valve between the right atrium and the right ventricle does not close completely, so each time the right ventricle contracts some blood leaks backward into the right atrium. Most often the valve itself is normal: the regurgitation is caused by enlargement of the right ventricle. Very slight ("trivial" or "physiological") regurgitation is a normal finding and needs no treatment.

The diagram shows the moment the right ventricle contracts. Normally the tricuspid valve leaflets are closed at this time, so blood does not flow back into the right atrium but leaves the ventricle for the lungs.

In tricuspid regurgitation the leaflets do not close completely while the ventricle contracts, and some blood flows back from the right ventricle into the right atrium. The atrium holds more blood and enlarges, which is why it is drawn larger here.

## Why it happens In most cases, more than 80%, the regurgitation is secondary: the valve itself is normal, but it does not close because the right ventricle or the right atrium has enlarged. The right ventricle enlarges when it is hard for it to push blood into the lungs. This happens with severe, long-standing lung disorders such as emphysema, with [pulmonary hypertension](../pulmonary-hypertension/), with disorders of the left side of the heart such as [heart failure](../heart-failure/), and rarely with narrowing of the pulmonary valve. The right atrium enlarges with long-standing [atrial fibrillation](../atrial-fibrillation/). Less often the valve itself is damaged (primary regurgitation). Causes include infection of the valve ([infective endocarditis](../infective-endocarditis/)), most often in people who inject drugs; birth defects of the valve; injury; rheumatic fever; and weakness of the valve tissue. Heart procedures are a separate cause: for example, the valve may be injured, or a pacemaker wire may stop it from closing properly. Tricuspid regurgitation (TR) is classified as primary or secondary; secondary TR accounts for more than 80% of cases. Secondary TR results from leaflet tethering with reduced leaflet coaptation, caused by annular dilation (typical of right atrial dilation due to chronic atrial fibrillation (AF); atrial secondary TR) and/or papillary muscle displacement, most commonly due to left heart disease causing pulmonary hypertension and leading to RV dilation or geometric distortion (ventricular secondary TR). Primary TR is less common. Its causes are blunt chest trauma, carcinoid syndrome, congenital defects (including Ebstein anomaly, downward displacement of a congenitally malformed tricuspid cusp into the RV), idiopathic myxomatous degeneration, Marfan syndrome, certain medications, rheumatic fever and valve damage from infective endocarditis. ## Symptoms Most often tricuspid regurgitation causes no symptoms. Some people notice pulsations in the neck caused by raised pressure in the veins and the right atrium. There may be discomfort in the right upper part of the abdomen because the liver is enlarged. Severe regurgitation can cause swelling of the legs, tiredness, a bloated and swollen abdomen from fluid building up in it, and loss of appetite. A heart rhythm disorder, atrial fibrillation or atrial flutter, may develop. TR is usually asymptomatic; some patients experience neck pulsations due to elevated jugular pressures. Symptoms of severe TR include peripheral oedema, fatigue, abdominal bloating, ascites and anorexia; patients may also develop symptoms of AF or atrial flutter. Signs of moderate to severe TR include jugular venous distension and sometimes an enlarged liver and peripheral oedema; in severe TR, systolic hepatic pulsation may be palpable. ## How it is diagnosed A doctor may suspect regurgitation from your history and an examination: from pulsations of the neck veins and a murmur heard through a stethoscope. But the murmur is not always heard, and it may disappear as the regurgitation gets worse. The main test is a [heart ultrasound (echocardiography)](../../diagnostic/echocardiography/). It shows the leaking valve and how much blood flows backward, which shows how severe the regurgitation is. Mild regurgitation is most often found by chance, on an echocardiogram done for another reason. An [ECG](../../diagnostic/ecg/) and a chest X-ray are often done. Depending on how severe the regurgitation is, cardiac MRI or cardiac catheterisation may be needed. The holosystolic murmur of TR is heard best at the left middle or lower sternal border and becomes louder with inspiration (Carvallo sign), but it is frequently not heard. The diagnosis is confirmed by echocardiography. Severe TR is characterised by at least one of the following (MSD lists them after the 2020 ACC/AHA guideline): two-dimensional failure of coaptation or a flail leaflet; a dense, triangular, early-peaking continuous-wave Doppler signal of the TR jet; a large flow convergence zone proximal to the valve; a large regurgitant jet on colour Doppler (≥50% of right atrial area); systolic flow reversal in the hepatic veins (specific for severe TR); vena contracta width greater than 7 mm. Cardiac MRI is the preferred method for evaluating RV size and function. Cardiac catheterisation is indicated for accurate measurement of pulmonary pressure when TR is severe and to evaluate coronary anatomy when surgery is planned. Before intervention in severe TR, careful evaluation of TR aetiology, stage of the disease (degree of TR severity, RV and LV dysfunction, and pulmonary hypertension), operative risk and likelihood of recovery by a multidisciplinary Heart Team is recommended. ## How it is treated Mild regurgitation usually needs little or no treatment. The main thing is to treat the disorder that caused the regurgitation, such as lung disease, pulmonary hypertension or disease of the left side of the heart; atrial fibrillation and heart failure also need treatment. Diuretics can relieve congestion, a build-up of fluid in the body. Surgery on the tricuspid valve is rarely done: mainly when the regurgitation is severe or when surgery on another heart valve is needed. If a person is having surgery on the mitral or aortic valve and the tricuspid regurgitation is severe, surgery on the tricuspid valve during the same operation is recommended; with moderate regurgitation, this should also be considered. For severe regurgitation, surgery on the tricuspid valve alone is recommended, or should be considered, if the regurgitation causes symptoms or the right ventricle is enlarging or starting to work less well, as long as the heart has not yet weakened too much and there is no severe pulmonary hypertension. During surgery the valve is repaired, for example by sewing in a ring that makes its opening smaller, or replaced with a prosthetic valve. Repair is generally preferred to replacement. If surgery is too risky and symptoms continue despite medicines, a transcatheter procedure on the valve may be considered, done with a catheter rather than open surgery; its aim is to improve quality of life and the condition of the right ventricle. If no surgery on other valves is needed and the right or left ventricle is already severely weakened, or there is a particular type of severe pulmonary hypertension (pre-capillary), the ESC flowchart points to medical therapy rather than a procedure on the valve. The treatment recommendation comes from a team of specialists (the Heart Team). People may tolerate regurgitation for years, but severe regurgitation eventually leads to heart failure. It is hard to recognise this early, so surgery is sometimes done too late to prevent lasting damage. Treatment of the cause is indicated; in secondary TR it may include antiarrhythmics, heart failure medications and pulmonary hypertension therapy. Diuretics can relieve congestion. TR in patients who need left-sided valve surgery (ESC 2025): concomitant tricuspid valve (TV) surgery is recommended in severe primary or secondary TR; concomitant TV repair should be considered in moderate primary or secondary TR, to avoid progression of TR and RV remodelling; it may be considered in selected patients with mild secondary TR and tricuspid annulus dilatation (≥40 mm or >21 mm/m²). NICE recommends considering surgical TV repair at the time of mitral valve surgery when TR is moderate or severe, and at the time of aortic valve surgery when TR is severe. The NICE rationale: severe secondary functional TR does not improve after fixing the mitral lesion, and patients with associated TR have a worse prognosis after mitral or aortic valve intervention. Severe TR without left-sided valve disease requiring surgery (ESC 2025): TV surgery is recommended in symptomatic patients with severe primary TR without severe RV dysfunction or severe pulmonary hypertension (PH). It should be considered in asymptomatic patients with severe primary TR who have RV dilatation or RV function deterioration, without severe LV/RV dysfunction or severe PH, and in patients with severe secondary TR who are symptomatic or have RV dilatation or RV function deterioration, without severe LV/RV dysfunction or PH. Transcatheter TV treatment should be considered to improve quality of life and RV remodelling in high-risk patients with symptomatic severe TR despite optimal medical therapy, in the absence of severe RV dysfunction or pre-capillary PH. Surgical options are annuloplasty (when TR is due to annular dilation) and valve repair or replacement (when TR is due to primary valve abnormalities or annuloplasty is not technically feasible); TV repair is generally preferred to replacement. ## When to see a doctor urgently Tricuspid regurgitation is usually well tolerated, but long-standing severe regurgitation may lead to heart failure and atrial fibrillation. Raised pressure in the right atrium and the large veins can make the liver and legs swell and cause symptoms of heart failure. The article on [heart failure](../heart-failure/) explains when heart failure needs an ambulance. In atrial fibrillation, blood clots may form in the enlarged atrium; a clot that breaks loose may block an artery and cause a stroke. The article on [atrial fibrillation](../atrial-fibrillation/) describes the signs of a stroke and when to call an ambulance.