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Tricuspid valve regurgitation is a condition in which blood leaks backward because the tricuspid valve, located between the right atrium and right ventricle of the heart, cannot close completely during contraction. When this valve mechanism, which functions like a one-way valve in a healthy heart, is impaired, the blood that should be pumped to the lungs for oxygenation leaks back toward the atrium. This valve problem, which profoundly affects heart health and systemic circulation, creates a workload on the right side of the heart that becomes increasingly difficult to manage over time. In short, this structural defect is a critical cardiological condition that disrupts the heart’s pumping power and impairs blood flow dynamics.
| Definition of the Disease | Tricuspid valve regurgitation is a heart valve disease in which part of the blood flows back into the right atrium when the right ventricle contracts because the tricuspid valve located between the right atrium and right ventricle cannot close completely. |
| Main Causes | The most common cause is functional valve regurgitation due to enlargement of the right ventricle. Other causes include rheumatic heart disease, congenital valve diseases, infective endocarditis, valve trauma, pacemaker electrodes, Ebstein anomaly, and, rarely, valve degeneration. |
| Risk Factors | Pulmonary hypertension, left-sided heart valve diseases, heart failure, atrial fibrillation, a history of rheumatic fever, intravenous substance use, and congenital heart diseases constitute risk factors. |
| Development of the Disease | When the valve cannot close completely, blood flows back into the right atrium with each heartbeat. Over time, the right atrium and right ventricle enlarge, and increased pressure may develop in the veins. |
| Symptoms | Weakness, easy fatigue, shortness of breath, abdominal swelling, edema in the legs and feet, prominence of the neck veins, liver enlargement, and palpitations may occur. |
| Early-Stage Findings | Mild tricuspid regurgitation often causes no symptoms and may be detected incidentally during routine echocardiography. |
| Advanced-Stage Findings | Significant right-sided heart failure, widespread edema, fluid accumulation in the abdomen (ascites), liver dysfunction, and a severe reduction in exercise capacity may develop. |
| Physical Examination Findings | A heart murmur in the lower right part of the chest, fullness in the neck veins, liver enlargement, edema in the lower extremities, and fluid accumulation in the abdomen may be observed. |
| Diagnostic Methods | Echocardiography is the primary diagnostic method. In addition, electrocardiography (ECG), chest X-ray, cardiac MRI, CT, and, when necessary, right heart catheterization may be performed. |
| Importance of Echocardiography | It is the most important imaging method for evaluating the degree of regurgitation, the size of the right heart chambers, right ventricular function, and pulmonary artery pressure. |
| Grades of the Disease | Tricuspid regurgitation is classified as mild, moderate, and advanced (severe). The treatment plan is determined according to this grading and the patient’s complaints. |
| Possible Complications | Right-sided heart failure, atrial fibrillation, liver dysfunction, deterioration in kidney function, progression of pulmonary hypertension, and a significant reduction in quality of life may develop. |
| Treatment Goals | The goals are to treat the underlying cause, reduce symptoms, preserve right heart function, and prevent complications. |
| Medication Treatment | Diuretics are used to reduce edema. If there is underlying heart failure, arrhythmia, or pulmonary hypertension, appropriate medication treatments are administered for these conditions. |
| Interventional Treatment | In suitable patients with high surgical risk, catheter-based tricuspid valve repair or replacement procedures may be considered in selected cases. |
| Surgical Treatment | Valve repair may be the preferred option in severe tricuspid regurgitation. Valve replacement may be performed when repair is not possible. |
| Conditions That May Require Surgery | Severe regurgitation, significant symptoms, deterioration in right ventricular function, or planned surgery for another heart valve may require surgical treatment. |
| Follow-Up Process | Patients should be monitored with regular cardiology examinations and echocardiography. The frequency of follow-up is determined according to the severity of the disease and the clinical condition. |
| Lifestyle Recommendations | Reducing salt intake, maintaining fluid balance, quitting smoking, maintaining an ideal weight, attending regular physician checkups, and following the recommended physical activity program are advised. |
| Regarding Pregnancy | While mild cases are generally well tolerated, pregnant women with severe tricuspid regurgitation require close cardiology and obstetrics follow-up. |
| Prevention | Preventing rheumatic fever, reducing the risk of infective endocarditis, and appropriately treating heart failure and pulmonary hypertension may help prevent disease progression. |
| Conditions Requiring Emergency Medical Evaluation | Emergency medical care should be sought if sudden severe shortness of breath, chest pain, fainting, rapid or irregular heartbeat, rapidly increasing edema, altered consciousness, or severe abdominal swelling develops. |
| Prognosis | The course of the disease depends on the degree of regurgitation, the underlying cause, right ventricular function, and the response to treatment. With early diagnosis and appropriate treatment, disease progression can be slowed and quality of life can be preserved. |
Through what mechanism does Tricuspid Valve Regurgitation develop in our heart?
The right side of the heart is responsible for collecting blood that has been used by the body and has a reduced oxygen level. This blood coming from all parts of the body first collects in the atrium of the heart. It then flows into the right lower chamber when the tricuspid valve opens. At the moment the heart contracts, all the blood in this chamber must be pumped to the lungs. At this exact moment of contraction, the three thin leaflets of the tricuspid valve must inflate like a parachute and lock tightly together. However, when the leaflets cannot come into contact with each other, the locking mechanism fails and a large portion of the blood begins to leak back in the direction from which it came.
This closure problem can occur in two different ways. In the first situation, there is direct physical damage, rupture, or tearing in the structure of the valve itself, its leaflets, or the thin fibrous tissues that support it. In the second and much more common situation, the valve itself is actually completely healthy. However, when the right lower chamber of the heart swells and enlarges like a balloon for various reasons, the circular frame in which the valve sits also stretches. Just as the leaves of a door cannot meet in the middle when the door frame stretches and widens, the valve leaflets cannot come together because of this enlargement. Blood continuously leaks backward through the resulting gap, and the disease gradually begins to become permanent.
Why does Tricuspid Valve Regurgitation develop and what are the underlying triggers?
The factors involved in the development of the disease are quite diverse. The most common condition we encounter is actually a reflection of another problem affecting the right side of the heart. If there is a disease in the mitral or aortic valves located on the left side of the heart, the left heart becomes fatigued over time and cannot pump blood forward adequately. In this case, blood begins to pool in the lungs and blood pressure in the pulmonary vessels rises. The right heart, which tries to pump blood against this increased high pressure, eventually becomes fatigued, its structure deteriorates, it enlarges, and it pulls on the ring where the valve sits, creating a basis for regurgitation. In addition, rhythm disorders that persist for many years without treatment may also enlarge the atria of the heart and disrupt the structure of the valve.
In cases where the valve is directly damaged, diseases experienced in the past come to the forefront. Rheumatic fever, especially when experienced during childhood, causes the valve leaflets to thicken and shrink later in life, resulting in loss of flexibility. Serious infections such as inflammation of the inner lining of the heart may literally destroy the valve tissue and cause sudden and severe leakage. Extremely strong physical blows to the chest may cause the thin cords that hold the valve in place to rupture suddenly. With today’s advancing technology, the wires extending into the heart from pacemakers or defibrillators implanted in many patients also sometimes pass directly through this valve. Over time, these wires may become trapped between the leaflets or damage the tissue through friction, physically preventing the valve from closing completely.
What complaints does the backward flow of blood cause in the body of patients with Tricuspid Valve Regurgitation?
When the leakage is mild, the heart can tolerate this extra load and the person may not feel any difference. However, as the disease progresses, the blood flowing backward creates excessive pressure in the body’s venous system. This causes fluid to accumulate in the tissues and leads to a series of symptoms that profoundly affect the patient’s quality of life.
The main symptoms most commonly experienced by patients are as follows:
- Swelling in the legs
- Ankle edema
- Abdominal tightness
- Prominent neck veins
- Loss of appetite
- Easy fatigue
- Shortness of breath
- Jaundice
These symptoms gradually take over the patient’s daily life. Due to the effect of gravity, fluid accumulation (edema), which initially begins in the ankles, spreads toward the legs over time. The patient becomes unable to wear shoes that previously fit comfortably. Fullness and pulsations that can be seen even from the outside begin in the veins of the neck with each heartbeat. One of the organs most affected by the backward pressure of the blood is the liver. The liver, which is continuously exposed to blood pooling, enlarges, its outer capsule stretches, and this causes the patient to feel constant pressure in the upper right part of the abdomen. Over time, free fluid accumulates inside the abdomen, the abdominal circumference enlarges, and the patient feels incredibly bloated even after eating only a few bites. Because the amount of oxygenated blood reaching the left heart decreases, patients become breathless even while walking very short distances, feel exhausted, and become unable to enjoy life.
How is Tricuspid Valve Regurgitation diagnosed and how is the degree of valve damage measured?
A definitive diagnosis of this disease and millimetric evaluation of the valve can be performed with the ultrasonographic imaging method called echocardiography. A standard examination performed from the surface of the chest usually provides the first signals. However, in order to view the valve structure in three dimensions and at high resolution, examine whether there is a ruptured cord, and determine how far apart the leaflets remain, a special ultrasound procedure performed from behind the heart through a thin tube passed down the esophagus is used.
During the measurement stage, the volume and velocity of the blood flowing backward and the diameter of the narrowest point through which it passes the valve are calculated using mathematical formulas with color flow imaging systems. The diameter of this backward-leaking jet exceeding certain millimeter values is the most important numerical evidence proving the severity of the disease. At the same time, the width of the frame in which the valve sits is measured precisely. If this frame has expanded far beyond normal limits, it is understood that the enlargement of the valve has exceeded a critical threshold. All these measurements allow physicians to predict the course of the disease and determine whether the time for intervention has arrived.
What are the grades of Tricuspid Valve Regurgitation and what do these stages mean?
The course of the disease and the direction of the treatment to be applied are determined according to stages that reflect the severity of the anatomical deterioration in the heart and the patient’s complaints. This classification serves as a map used when developing the treatment strategy.
The basic stages of the disease are as follows:
- First-degree mild regurgitation
- Second-degree moderate regurgitation
- Third-degree advanced regurgitation
- Fourth-degree severe regurgitation
First-degree regurgitation is an extremely natural condition detected incidentally during routine examinations in a very large portion of the population, does not impair the functioning of the heart, and does not require treatment. By the second degree, the leakage in the heart has become more apparent and the frame is observed to have enlarged slightly. The patient may become tired during strenuous exertion, but the condition can generally be kept under control with close follow-up and lifestyle changes.
When the disease reaches the third stage, the situation begins to become more difficult. The leakage area has widened considerably, and the right side of the heart has become noticeably ballooned. The patient now needs regular diuretic medication and has to struggle continuously with swelling in the legs. In the fourth and most severe stage, the right heart has reached the point of giving up. Irreversible organ damage begins, liver functions deteriorate, the patient develops resistance to medication, and becomes unable to breathe even with the slightest movement. This stage is the most critical period in which mechanical intervention on the valve becomes unavoidable.
What modern methods are used in the treatment of Tricuspid Valve Regurgitation without open-heart surgery?
For many years, the unchanging solution for heart valve diseases was open-heart surgery. However, when the valve in question is located on the right side of the heart, the risks associated with open surgery reach a very different dimension. These patients are generally elderly, have previously undergone other valve surgeries, and have liver and kidney functions that have been worn down by long-term disease. Reopening the chest in such an exhausted body, connecting the patient to a heart-lung machine, and completely stopping the heart is often a process with a very high risk of death.
Thanks to the revolutions in engineering and technology in the medical world, we are no longer condemned to this desperate situation. The field known as interventional cardiology has developed closed-system treatments for patients considered too high-risk to tolerate the burden of open surgery, in which the heart is reached through a vein in the groin. These non-surgical procedures, called transcatheter methods, have become a lifeline by offering the opportunity to repair the valve problem from within or completely block its destructive effects while the patient’s breastbone remains uncut and the heart continues beating.
What are the steps of the clipping procedure performed for Tricuspid Valve Regurgitation?
The most successful non-surgical method used when the valve leaflets cannot close and leave a gap in the middle is repairing the valve from within with the help of a clip. The basic principle is to lock the leaflets that have moved apart together in the middle with a clip and transform one large leakage opening into two smaller and leak-resistant openings.
The preparation and application stages of this procedure are as follows:
- Comprehensive imaging
- A small entry through the groin
- Advancement of the guide tube
- Delivery of the clip to the valve
- Grasping the leaflets
- Measurement of the amount of leakage
- Leaving the clip in the heart
The process begins with millimetric computer and ultrasound calculations performed long before the procedure. On the day of the procedure, the patient is placed under light sedation. Entry is made through the main vein in the right groin with the help of a very thin needle, and a very long steerable tube is advanced through the vessels into the upper right chamber of the heart. The system, which has a special and highly sensitive clip mechanism at its tip, is passed through this tube. With the help of simultaneous live ultrasound images, the physician positions the clip directly over the valve at the correct angle with millimetric precision.
The arms of the clip are slowly opened and pulled upward from beneath the valve, meaning from the ventricular side of the heart, so that the moving leaflets are captured within these arms. The system is not released immediately when the leaflets are locked; the physician first examines how much the leakage has been reduced using color ultrasound. If the locking is not perfect or the forward blood flow has become narrower than necessary, the clip can be opened and repositioned. When the result is satisfactory, the clip is completely released and permanently begins performing its function inside the heart. If necessary, several clips may be placed side by side on the valve.
What benefits do the closed methods used in the treatment of Tricuspid Valve Regurgitation provide to the patient?
The reliability of this clipping procedure performed through the groin has been proven in the medical literature through large scientific studies involving thousands of patients worldwide. These data clearly demonstrate that the greatest contribution this technology offers high-risk patients is long-term safety and improved quality of life.
In the first months following the procedure, the severity of valve leakage decreases by at least one or two grades in a very large proportion of patients. This mechanical improvement is reflected directly in the patient’s life like a miracle. Patients who previously could not take two steps on a flat road and who woke suddenly from sleep at night because of shortness of breath show an extraordinary improvement in exercise tests and quality-of-life surveys performed after the procedure. Compared with patients who try to eliminate edema only with medication, the abdominal swelling of patients who undergo the clipping procedure decreases much more quickly, their need to visit hospital emergency departments continuously disappears, and they regain the freedom to return to their social lives much more independently.
Which systems are used when the valve cannot be completely repaired for Tricuspid Valve Regurgitation?
Sometimes the disease reaches such a late stage that the valve leaflets have moved so far apart that even the arms of the clips cannot reach them. Alternatively, due to previous diseases, the valve may become calcified like stone and completely lose its flexibility. In such cases, neither repair from within nor replacement of the valve through open surgery is possible. For these patients who have reached the final stage of heart failure, medicine has developed a different strategy aimed at treating the consequence of the problem rather than its source.
In this strategy, the defective valve in the heart is not touched at all. The main objective is to prevent the blood striking forcefully backward from the heart from damaging the liver, kidneys, and legs. For this purpose, two specially manufactured biological valves are placed directly inside the lower and upper main veins that carry blood to the heart, again through the groin. These new valves act as a barrier against the wave of blood flowing backward with each heartbeat. Thus, even though the heart continues to leak, the organs are protected from this destructive pressure. Shortly after the procedure, pooling in the organs ends, the kidneys are relieved and begin filtering again, and the patient is freed from severe edema and can breathe comfortably.
What are the differences between interventional closed methods and open surgery in the treatment of Tricuspid Valve Regurgitation?
Selecting the treatment most suitable for the patient’s body and the structure of the disease is one of the issues to which modern medicine attaches the greatest importance. There are enormous differences between traditional open surgery and today’s modern transcatheter methods that determine the patient’s hospital course and speed of recovery.
The most fundamental differences between these methods are as follows:
- Preservation of the integrity of the breastbone
- No use of a heart-lung pump
- Reduced need for deep general anesthesia
- Low risk of bleeding and infection
- Shorter hospital stay
- Very rapid return to daily life
In young, low-risk patients with strong bone structure and no other heart problems, conventional open-heart surgery remains one of the most reliable treatment options. The surgeon opens the chest, sees the valve directly, sews a support ring around the valve, and narrows it to provide a permanent solution. However, after this procedure, healing of the breastbone, overcoming the risk of infection, and bed rest may take months.
In contrast, closed methods cause almost no physical trauma to the patient’s body. Because no bone is cut, the heart is not stopped, and the patient is not connected to machines under deep anesthesia, waking up and standing after the procedure are very rapid. Since there are no large surgical incisions, the risk of wound infection is almost negligible. The patient generally begins walking the day after the procedure, is discharged from the hospital within a short time, and can easily resume daily social life within a few days without requiring the months-long rehabilitation process associated with conventional surgeries.
Who can undergo the innovative non-surgical procedures developed for Tricuspid Valve Regurgitation?
These advanced technologies that have revolutionized the medical world are not suitable for every patient. The method to be selected is not determined by the decision of a single physician, but by councils in which cardiologists, cardiac surgeons, and anesthesiologists come together and evaluate the patient’s condition down to the finest detail.
The patient characteristics considered most suitable for these procedures are as follows:
- Advanced age
- Physical frailty
- History of previous open-heart surgery
- High surgical risk score
- Suitable valve structure and anatomy
If a patient has the potential to face a life-threatening risk on the open surgery table, has very low physical resilience, or has already undergone an operation in which the chest was opened once before, the patient is not subjected to another open operation and is directed straight to closed methods. However, for this procedure to be performed, it is also critical that the heart has not become completely exhausted. If blood pressure in the pulmonary vessels has risen to irreversible levels or the right heart has permanently lost its contractile strength, these devices may also fail to provide benefit. In addition, ultrasound imaging must show that the structure of the valve is of sufficient quality to hold the clips.
What kind of process awaits patients at home after treatment for Tricuspid Valve Regurgitation?
Repairing the valve with a successful operation is the greatest step in treatment, but the process does not end there. The lifestyle changes the patient makes after returning home directly determine how long-lasting this major success will be. Although a patient treated with a closed method returns home very quickly, the patient is asked to avoid lifting very heavy objects and movements requiring sudden and intense exertion during the first few weeks. Care is taken to ensure that the entry site in the groin heals without problems. During this period, the dose of diuretic medication is adjusted day by day under physician supervision in order to gradually reduce the workload of the heart. As the heart becomes relieved, the patient’s dependence on medication also decreases.
The most critical key to this recovery process is nutrition. Salt consumption must be strictly restricted to prevent fluid accumulation in the body and water retention inside the vessels from placing pressure on the heart. In addition to avoiding salt shakers at the table, packaged and processed foods with very high sodium content should also be removed from our lives. As the body begins to regain strength, exercise capacity should be increased with light walking and the patient’s participation in an active life should be supported.
Frequently Asked Questions
Prof. Dr. Kadriye Orta Kılıçkesmez is one of the leading figures in the field of Turkish cardiology. She was born on January 24, 1974, in Tekirdağ. After completing her undergraduate education at Istanbul University Cerrahpaşa Faculty of Medicine, she chose cardiology as her specialty and received her specialist training at the Cardiology Institute of the same university. In 2015, she was appointed by the university to establish the Şişli Etfal cardiology clinic and Angio laboratory. Becoming a professor in 2017, Kadriye Kılıçkesmez established the cardiology clinic and Angio laboratory of Prof. Dr. Cemil Taşçı Hospital in 2020 and ensured that the clinic became a training clinic.
