Severe tricuspid valve insufficiency is most likely caused by rheumatic heart disease, and severe damage to the tricuspid valve causes insufficiency, which is the most common cause. The presence of severe tricuspid valve insufficiency in the elderly may be related to degenerative changes in the valve, which is a change in aging. There is also the relative nature of tricuspid insufficiency, which is caused by an enlarged heart, commonly due to dilated cardiomyopathy or primary cardiomyopathy. As the heart enlarges the heart’s annulus is also relatively enlarged, and the area of the tricuspid valve orifice is enlarged, but the area of the tricuspid valve does not increase, thus causing severe closure insufficiency.