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# Tricuspid regurgitation and tricuspid valve disease

The valve between the [right atrium](https://durgical.com/en/anatomy/right-atrium/) and right ventricle leaks, so blood flows backwards. It often follows lung or left-heart disease.

Updated 2026-11-01

## Structures involved

Tap one to see what it is and open it in 3D.

- [Tricuspid anterior leaflet](https://durgical.com/en/anatomy/superior-leaflet-of-right-atrioventricular-valve/)
- [Tricuspid posterior leaflet](https://durgical.com/en/anatomy/inferior-leaflet-of-right-atrioventricular-valve/)
- [Tricuspid septal leaflet](https://durgical.com/en/anatomy/septal-leaflet-of-right-atrioventricular-valve/)
- [Right atrium](https://durgical.com/en/anatomy/right-atrium/)
- [Right ventricle](https://durgical.com/en/anatomy/right-ventricle/)
- [Valve rings (fibrous skeleton)](https://durgical.com/en/anatomy/fibrous-rings-of-the-heart-valves/)
- [Chordae tendineae](https://durgical.com/en/anatomy/chordae-tendineae-of-right-atrioventricular-valve/)
- [Right ventricle papillary muscles](https://durgical.com/en/anatomy/papillary-muscles-of-right-ventricle/)
- [Inferior vena cava](https://durgical.com/en/anatomy/inferior-vena-cava/)
- [Superior vena cava](https://durgical.com/en/anatomy/superior-vena-cava/)
- [Pulmonary arteries](https://durgical.com/en/anatomy/right-pulmonary-artery/)

## Why it happens

- [Hyperemia and congestion (the nutmeg liver, heart-failure cells)](https://durgical.com/en/general-pathology/hyperemia-and-congestion/)
- [Central venous pressure and the jugular pulse](https://durgical.com/en/physiology/central-venous-pressure-and-the-jugular-pulse/)
- [Murmurs and the hemodynamics of valve disease](https://durgical.com/en/physiology/murmurs-and-the-hemodynamics-of-valve-disease/)

## What it is

Tricuspid regurgitation (TR) is backflow of blood from the right ventricle into the right atrium during systole because the tricuspid valve does not close properly. Most cases are secondary (functional): the leaflets are normal but the annulus and right ventricle are dilated by pressure or volume overload. Primary TR comes from disease of the leaflets or chordae themselves. Tricuspid stenosis is rare and is almost always rheumatic, usually together with mitral disease.

## Who gets it

Trivial TR is found on echocardiography in most healthy people and is not a disease. Clinically significant TR becomes more frequent with age, in women and in people with atrial fibrillation, pulmonary hypertension or left-sided valve disease. In Colombia and Latin America, rheumatic heart disease and Chagas cardiomyopathy remain relevant causes of right-heart dilation, alongside chronic lung disease.

## Causes

- Secondary (about 80–90%): pulmonary hypertension from left-heart disease (mitral valve disease, left ventricular failure), chronic lung disease or pulmonary embolism; right ventricular infarction or cardiomyopathy; atrial fibrillation with annular dilation
- Primary: infective endocarditis (classically Staphylococcus aureus in people who inject drugs), rheumatic heart disease, carcinoid heart disease, myxomatous degeneration or prolapse
- Congenital: Ebstein anomaly, tricuspid valve dysplasia
- Device- and injury-related: pacemaker or defibrillator leads crossing the valve, [chest](https://durgical.com/en/anatomy/region/chest/) trauma, damage during endomyocardial biopsy
- Drugs: ergot-derived dopamine agonists and some serotonergic appetite suppressants (valvulopathy)

## Risk factors

- Pulmonary hypertension of any cause
- Left-sided valve disease, especially mitral stenosis or regurgitation
- Atrial fibrillation and older age
- Injection drug use (endocarditis)
- Transvenous pacemaker or defibrillator leads

## Pathophysiology

With each ventricular contraction part of the right ventricular stroke volume returns to the right atrium. Right atrial pressure rises and is transmitted to the venae cavae, liver and peripheral veins, producing raised jugular pressure with large systolic v waves, hepatic congestion, ascites and oedema. The extra volume dilates the right ventricle and annulus further, which worsens the leak (TR begets TR). Forward flow to the lungs falls, so fatigue and low output appear late. Chronic hepatic congestion can lead to cardiac (congestive) cirrhosis, and low renal perfusion with venous congestion causes cardiorenal dysfunction.

## Classification

- Primary (organic, leaflet disease) vs secondary (functional, annular and ventricular dilation); atrial functional TR in atrial fibrillation
- Severity on echocardiography: mild, moderate, severe (some systems add massive and torrential)
- Stages A–D (at risk, progressive, asymptomatic severe, symptomatic severe)
- Tricuspid stenosis: usually rheumatic and combined with mitral disease

## Symptoms and signs

- Often silent when mild; symptoms reflect the cause (for example dyspnoea from pulmonary hypertension or left-heart disease)
- Fatigue and reduced exercise tolerance
- Leg and ankle oedema, abdominal swelling (ascites) and right upper quadrant discomfort from liver congestion
- Pulsations felt in the neck
- Loss of appetite, early satiety and weight loss in advanced disease

## Red flags

- Fever with a new right-sided murmur in a person who injects drugs (endocarditis, septic pulmonary emboli)
- Rapidly increasing oedema, ascites or falling urine output (decompensated right heart failure)
- Jaundice or worsening liver tests (congestive hepatopathy)
- Syncope or hypotension (low output, arrhythmia)

## Diagnosis

**Clinical**
Holosystolic murmur at the left lower sternal border that increases with inspiration (Carvallo sign); raised jugular venous pressure with prominent systolic v waves; pulsatile, enlarged [liver](https://durgical.com/en/anatomy/liver/); ascites and peripheral oedema; right ventricular heave. The murmur may be soft or absent when the leak is massive.

**Tests**
ECG: right atrial enlargement, right ventricular hypertrophy or [right bundle branch](https://durgical.com/en/anatomy/right-bundle-branch/) block, often atrial fibrillation. Natriuretic peptides, renal and liver function (congestion), blood cultures when endocarditis is suspected.

**Imaging**
Transthoracic echocardiography is the key test: leaflet anatomy, mechanism, severity by colour and Doppler (vena contracta, systolic hepatic vein flow reversal), annular and right ventricular size and function, and an estimate of pulmonary artery pressure. Cardiac MRI quantifies right ventricular volumes; right heart catheterisation clarifies pulmonary vascular resistance before surgery.

## Differential diagnosis

- Mitral regurgitation (apical murmur radiating to the axilla, does not increase with inspiration)
- Ventricular septal defect
- Constrictive pericarditis or restrictive cardiomyopathy (raised jugular pressure, ascites)
- Cirrhosis of primary liver origin
- Nephrotic syndrome and other causes of generalised oedema

## Goal of treatment

Treat the underlying cause, relieve venous congestion and repair or replace the valve before irreversible right ventricular dysfunction develops.

## Treatment

**Medical**
Loop diuretics (sometimes with aldosterone antagonists) to relieve oedema, ascites and liver congestion.

**Medical**
Treat the cause: left-sided heart failure and valve disease, pulmonary hypertension, rate or rhythm control of atrial fibrillation, antibiotics for endocarditis.

**Surgical**
Tricuspid annuloplasty or repair, most often during left-sided valve surgery when TR is severe or the annulus is dilated; isolated repair or replacement for severe symptomatic TR before the [right ventricle](https://durgical.com/en/anatomy/right-ventricle/) fails.

**Procedure**
Transcatheter tricuspid repair (edge-to-edge) or replacement in selected patients at high surgical risk.

**Follow-up**
Nursing: daily weight, fluid balance and oedema, abdominal girth, renal function and electrolytes on diuretics, signs of infection in people who inject drugs; periodic echocardiography.

## Complications

- Right-sided heart failure
- Congestive hepatopathy and cardiac cirrhosis
- Cardiorenal syndrome
- Atrial fibrillation and flutter
- Septic pulmonary emboli in tricuspid endocarditis
- Protein-calorie malnutrition (cardiac cachexia)

## Prognosis

Mild TR is benign. Severe TR is independently associated with higher mortality, and outcomes depend on the cause and on right ventricular function. Results of surgery are best when it is done before the right ventricle and liver are irreversibly damaged.

## Prevention

- Prevention and treatment of streptococcal pharyngitis and rheumatic fever
- Early treatment of left-sided valve disease and pulmonary hypertension
- Harm-reduction programmes for people who inject drugs
- Careful lead placement and follow-up in people with intracardiac devices

## Test yourself

Think of the answer, then tap the question to see it.

## What happens to the TR murmur with inspiration, and what is this sign called?

It becomes louder (Carvallo sign), because venous return to the right heart increases.

## What is the most common mechanism of tricuspid regurgitation?

Secondary (functional) TR from right ventricular and annular dilation, usually due to pulmonary hypertension or left-heart disease.

## Which organism classically causes tricuspid endocarditis in people who inject drugs?

Staphylococcus aureus.

## Which jugular venous waveform finding is typical of severe TR?

Large systolic (c-v) waves.

## Which tumour syndrome causes right-sided valve fibrosis with TR and pulmonary stenosis?

Carcinoid syndrome with liver metastases (carcinoid heart disease).

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## Related conditions

- [Pulmonary hypertension and cor pulmonale](https://durgical.com/en/conditions/pulmonary-hypertension-and-cor-pulmonale/)
- [Heart failure](https://durgical.com/en/conditions/heart-failure/)
- [Infective endocarditis](https://durgical.com/en/conditions/infective-endocarditis/)
- [Rheumatic heart disease](https://durgical.com/en/conditions/rheumatic-heart-disease/)
- [Ebstein anomaly](https://durgical.com/en/conditions/ebstein-anomaly/)
- [Carcinoid syndrome](https://durgical.com/en/conditions/carcinoid-syndrome/)
- [Atrial fibrillation](https://durgical.com/en/conditions/atrial-fibrillation/)
- [Mitral stenosis](https://durgical.com/en/conditions/mitral-stenosis/)
- [Mitral regurgitation](https://durgical.com/en/conditions/mitral-regurgitation/)
- [Chronic obstructive pulmonary disease (COPD)](https://durgical.com/en/conditions/chronic-obstructive-pulmonary-disease/)
- [Pulmonary embolism](https://durgical.com/en/conditions/pulmonary-embolism/)
- [Cirrhosis](https://durgical.com/en/conditions/cirrhosis/)

Educational information, not medical advice. For any symptom, see a health professional.

Sources: [Tricuspid regurgitation](https://medlineplus.gov/ency/article/000169.htm) (MedlinePlus, US National Library of Medicine, 2026).

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Representative model, for educational purposes only.

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Source: https://durgical.com/en/conditions/tricuspid-regurgitation-and-tricuspid-valve-disease/
License: CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). Cite as: DurgiPedia (durgical.com), https://durgical.com/en/conditions/tricuspid-regurgitation-and-tricuspid-valve-disease/