Prof Marianna Adamo introduces proceedings, before Prof Marta Sitges discusses the shifting landscape of TR and the updated evidence guiding referral decisions. With improved imaging and expanding transcatheter options, clinicians are now better equipped to intervene earlier in the disease course. Prof Sitges outlines current ESC recommendations, focusing on TR aetiology, early clinical red flags, and the essential role of multimodality assessment. She highlights the challenges of recognising symptoms and accurately grading severity, particularly in secondary TR. A central takeaway is the importance of timely referral. Patients with confirmed severe TR – and those with moderate TR plus systemic symptoms – should be evaluated in a specialist valve centre to determine the most appropriate treatment pathway.

Dr Ali Vazir presents a case demonstrating how targeted medical therapy can significantly improve TR. An 82-year-old man with congestion and moderate–severe TR underwent intensive optimisation of diuretics and heart failure medication, resulting in weight loss, improved biomarkers and a meaningful reduction in TR severity. The session emphasises that TR is dynamic and often improves with effective decongestion. Close follow-up – using NT-proBNP and echocardiography – is essential, with heart team reassessment if symptoms or congestion recur. The case reinforces the value of medical optimisation in stabilising patients and guiding decisions on when referral for transcatheter or surgical therapy is appropriate.

Dr Ali Vazir presents an 81-year-old man with breathlessness and massive–torrential TR. Despite preserved LV function and no overt congestion, investigations showed high NT-proBNP, significant annular dilatation, complex leaflet anatomy and mild right-sided dysfunction. Multimodality assessment – including TOE, right heart catheterisation, MRI and CT – was essential to clarify severity and determine anatomical suitability. Medical optimisation for hypertension and HFpEF was initiated but did not reduce TR. With low surgical risk and favourable anatomy, the patient was reviewed by the heart team to consider surgical or transcatheter treatment, including the EVOQUE system.

Continuing the patient journey of Case 2 – presenting with persistent symptoms and complex severe TR – as highlighted by Dr Ali Vazir, Dr Sam Dawkins explains why transcatheter replacement was the chosen strategy. Despite low surgical risk by scoring, isolated tricuspid surgery is rarely offered in older patients, and the valve’s multi-leaflet, multi-jet anatomy made edge-to-edge repair unlikely to achieve a good result. The team selected the EVOQUE system, supported by TRISCEND II data showing substantial benefit in massive–torrential TR. The assessment pathway, key imaging steps and straightforward recovery are briefly outlined. Important considerations include annular size constraints, the need for adequate RV function, and maintaining stable diuretics and appropriate anticoagulation after replacement.

In this final section, Dr Ali Vazir describes the case of a 66-year-old woman with torrential TR, recurrent admissions and major liver, kidney and RV dysfunction. Despite maximal diuretic therapy, she remains severely symptomatic with prohibitive surgical risk and poor expected survival. Imaging confirms a large coaptation gap, marked annular dilatation and severely reduced RV function – features that make both surgical and transcatheter treatment unfeasible. In such late-stage presentations, management is often limited to supportive or palliative care. The faculty conclude by stressing early recognition, timely referral and careful heart-team assessment to avoid patients progressing to a point where intervention is no longer possible.