Before the Window Closes

Corresponding Author

Severe tricuspid regurgitation (TR) has historically occupied an uncomfortable place in cardiovascular medicine—common, clinically important, and yet too often tolerated until patients become profoundly symptomatic. For years, TR was viewed as the “forgotten valve,” a downstream consequence of left-sided disease or atrial remodeling rather than a primary therapeutic target. Patients frequently arrived late in their disease course, burdened by edema, renal dysfunction, hepatic congestion, cachexia, and progressive frailty, only to be deemed prohibitively high risk for surgery. In many cases, clinicians focused on escalating diuretics while accepting ongoing systemic venous congestion as inevitable.

In this issue of JACC: Case Reports, the case presented by Marek-Iannucci et al¹ challenges that mindset directly. Their report describes an 85-year-old patient with torrential TR, worsening cardiorenal syndrome, hepatic congestion, and advanced right-sided heart failure who underwent transcatheter tricuspid valve replacement (TTVR) with the EVOQUE system, followed by rapid clinical recovery and striking improvement in end-organ function. Although this is a single case, it captures an increasingly important conceptual shift in structural heart disease: Significant TR is not simply a valvular lesion.¹ It is also a disease of chronic systemic venous congestion.

That distinction matters. And, as demonstrated by this case—these systemic abnormalities driven by severe tricuspid regurgitation can be dynamic and potentially reversible.1, 2, 3

In this report, patient improvement following TTVR extended beyond echocardiographic reduction in TR severity. The patient experienced rapid decongestion, improved NYHA functional class, reduction in B-type natriuretic peptide, normalization of inferior vena cava dimensions, improvement in bilirubin, and recovery of renal function.¹ Particularly compelling is the temporal relationship between elimination of severe TR and improvement in creatinine and estimated glomerular filtration rate, supporting the increasingly recognized role of venous congestion as a major driver of cardiorenal syndrome.

This observation aligns with emerging data from the transcatheter tricuspid literature. Early experiences with both transcatheter edge-to-edge repair and TTVR have demonstrated improvements in symptoms, quality of life, functional status, and markers of congestion. Importantly, the physiologic response often appears disproportionate to what might be expected from a “single valve intervention.” Patients frequently describe dramatic changes in exercise tolerance, abdominal fullness, edema, and energy level within days to weeks.4, 5, 6 These clinical responses reinforce the idea that severe TR may act as a systemic disease amplifier.

The case also highlights another critical issue in contemporary TR care: timing.

By the time many patients are referred for intervention, irreversible right ventricular dysfunction, severe end-organ damage, pulmonary vascular disease, or frailty may already be present. Unlike left-sided valve disease, where decades of data have established relatively clear intervention thresholds, TR continues to suffer from delayed recognition and therapeutic inertia.⁷ Symptoms such as fatigue, edema, ascites, and exercise intolerance are often attributed to age, atrial fibrillation, pulmonary disease, or “chronic heart failure,” rather than recognized as manifestations of progressive venous congestion from severe TR.

As transcatheter therapies mature, the field may need to rethink how procedural candidacy is assessed. Historically, severe renal dysfunction or hepatic congestion were often viewed primarily as advanced disease states and potentially markers of prohibitive procedural risk. Increasingly, however, these findings may represent part of the therapeutic target itself. The question is no longer simply whether a patient is sick enough to justify intervention, but whether intervention is occurring early enough to preserve reversibility.

This concept is especially relevant in patients with preserved longitudinal right ventricular function despite advanced congestion, as seen in this case. Conventional right ventricular metrics may underestimate physiologic burden in chronic TR because the right ventricle operates in a low-impedance, volume-overloaded state. Patients can therefore appear deceptively “compensated” until venous congestion and systemic consequences become profound. Careful integration of imaging, clinical congestion markers, renal function, hepatic indices, and functional status may be more informative than any single echocardiographic parameter alone.

The present report also underscores the growing importance of multimodality imaging and heart team evaluation in TR intervention. The patient's mechanism of regurgitation was complex, involving annular dilation, atrial and ventricular remodeling, and pacemaker lead impingement.^1,6,8 Contemporary structural imaging increasingly requires not simply quantification of TR severity, but detailed characterization of mechanism, leaflet anatomy, coaptation gap, device interaction, right ventricular adaptation, and procedural feasibility. As transcatheter options expand, imaging has become central not only to procedural guidance, but also to patient selection and prediction of reversibility.

Importantly, enthusiasm for TTVR must still be balanced with caution. The long-term durability of replacement systems, optimal anticoagulation strategies, right ventricular adaptation after abrupt elimination of TR, and ideal patient selection criteria remain active areas of investigation. Not all patients with severe TR will benefit equally, and some may already have reached a stage where right ventricular failure or multisystem disease is no longer reversible. The field is still defining the “window of opportunity” during which intervention produces maximal benefit.

The tricuspid valve may no longer be the forgotten valve. Increasingly, it is becoming a window into the systemic consequences of chronic congestion—and a reminder that some forms of advanced heart failure may be more reversible than we once believed.

Funding Support and Author Disclosures

Dr Haeffele serves as a consultant for Edwards Lifesciences, Medtronic, Echo IQ, and Laza Medical; and serves as a site investigator for structural heart disease clinical trials sponsored by industry.