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Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.

Tricuspid and pulmonary valve disease

Cardiology · UK scope · Sources checked 27 Aug 2026 · Clinical review pending

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Escalate

Hypotension, syncope, cyanosis or rapidly worsening venous congestion with severe tricuspid or pulmonary valve disease requires same-day specialist assessment; shock needs emergency echocardiography and critical-care/valve-team escalation.

Synopsis

Recognise right-sided valve disease, define RV consequences and refer before irreversible right-heart failure.

  • Most tricuspid regurgitation (TR) is secondary to annular dilatation from left-heart disease, pulmonary hypertension, atrial fibrillation or RV remodelling; exclude device-lead injury and endocarditis.
  • Severe TR causes giant v waves, a pulsatile liver, ascites, oedema and a pansystolic murmur that increases on inspiration; a quiet murmur does not exclude advanced disease.
  • Pulmonary stenosis is usually congenital; pulmonary regurgitation commonly follows repaired tetralogy of Fallot or prior valvotomy/conduit surgery.
  • TTE grades lesion severity and assesses RV size/function and pulmonary pressure; CMR is especially valuable when RV volumes or pulmonary regurgitant fraction will determine intervention.
  • Diuretics relieve congestion but do not correct the valve or halt progressive RV dysfunction.
  • Moderate or severe TR should be considered for repair when mitral surgery is already planned; isolated severe disease needs early valve-centre review before major RV or end-organ damage.
  • Balloon pulmonary valvuloplasty suits significant doming valvar stenosis; dysplastic valves, sub/supravalvar obstruction or associated lesions may require surgery.
  • A dysfunctional RV-to-pulmonary-artery conduit may be treated by transcatheter pulmonary valve implantation in an adult congenital heart disease centre when anatomy is suitable.

Key red flags

Pulmonary stenosis phenotype

Ejection click, harsh upper-left-sternal systolic murmur, RV heave and exertional dyspnoea/syncope suggest significant RV outflow obstruction.

Acute severe TR

Fever, injection-drug exposure or an intracardiac lead with new right-heart failure raises endocarditis or lead-related injury; obtain cultures and urgent imaging.

Decompensation

Hypotension, cool peripheries, oliguria, lactate rise, syncope or cyanosis indicates low output or critical obstruction and needs emergency escalation.

Investigation priorities

01
12-lead ECG and rhythm monitoringFirst step

Detect AF, atrial enlargement, RV hypertrophy and ventricular arrhythmia.

Management branches

TRSevere tricuspid regurgitation

Severe TR with symptoms, RV enlargement/dysfunction, end-organ congestion or planned left-sided surgery.

  1. Confirm primary versus secondary mechanism and optimise AF, left-sided valve disease, pulmonary pressure and congestion.
  2. If mitral surgery is planned and TR is moderate or severe, discuss concomitant tricuspid repair with the Heart Team.
  3. If isolated severe primary TR is symptomatic or causing progressive RV dilatation, refer early for repair/replacement assessment before severe RV or hepatic dysfunction.
  4. If surgery is prohibitive, obtain TOE/CT anatomical assessment for a specialist transcatheter option; if anatomy is unsuitable, continue structured decongestion and advanced-HF review rather than declaring the lesion benign.

Key medicines

FurosemideUsually 20-40 mg by mouth once daily initially; titrate to congestion and renal response, with IV treatment for acute decompensation.Check blood pressure, weight, sodium, potassium and creatinine; excessive diuresis can reduce preload and cardiac output in RV failure or severe obstruction.
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Sources and review status5 sources · checked 27 Aug 2026 · clinical review pending+
Sources

Sources and review status

National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.

  • NICE NG208: Heart valve disease presenting in adultsUK investigation, referral and tricuspid-intervention recommendations.
  • 2025 ESC/EACTS valvular heart disease guidelineCurrent specialist framework for right-sided valve assessment and intervention.
  • 2020 ESC adult congenital heart disease guidelinePulmonary stenosis, pulmonary regurgitation and RVOT/conduit pathways.
  • NICE HTG297: Percutaneous pulmonary valve implantationUK procedural governance for RVOT dysfunction.
  • NICE IPG731: Transcatheter tricuspid valve leaflet repairUK procedural evidence and governance context.

Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem · Content changes

Authoring stateRapid draftClinical stateAwaiting reviewJurisdictionUnited Kingdom