Multimodality imaging for surgical decision-making in tricuspid regurgitation: from referral to intraoperative assessment

Tricuspid regurgitation (TR) is a clinical syndrome in which integrated multimodality imaging is central to diagnosis, timely referral, procedural selection, and assessment of treatment success. This narrative state-of-the-art review focuses on the imaging information that changes decisions along the surgical pathway while positioning surgery within contemporary transcatheter practice. Transthoracic echocardiography remains the gateway examination; three-dimensional transoesophageal echocardiography refines leaflet and annular anatomy; cardiac magnetic resonance provides the most reproducible assessment of right ventricular volumes and function; and cardiac computed tomography defines annular geometry, adjacent structures, device leads, and access. We distinguish guideline-endorsed thresholds from observational or consensus-derived decision aids and link mechanism, annular dilatation, leaflet tethering, right ventricular reserve, pulmonary haemodynamics, and end-organ risk to the choice of repair, replacement, transcatheter therapy, or surveillance. Particular emphasis is placed on perioperative imaging: the effects of anaesthesia and loading conditions, accurate septolateral annular measurement, the definition of an acceptable post-bypass result, and the significance of central vs. eccentric residual jets. A dedicated section compares imaging requirements for transcatheter edge-to-edge repair and transcatheter tricuspid valve replacement and summarizes post-procedural surveillance. The central message is that imaging does not replace clinical judgement; it provides the shared language through which the Heart Team selects the right intervention before irreversible right-heart and end-organ damage develops.