Tricuspid regurgitation classification
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Rim Halaby, M.D. [2] Fatimo Biobaku M.B.B.S [3] Basir Gill, M.B.B.S, M.D.[4]
Overview
Overview
Tricuspid regurgitation (TR) can be broadly classified as primary or secondary. Primary (or organic) TR results from an organic lesion of the tricuspid valve itself, whereas secondary (or functional) TR is caused by left heart failure or pulmonary hypertension without an intrinsic abnormality of the tricuspid valve.
Classification
Classification
Mechanistically, TR can be classified as primary, secondary or cardiac implantable electronic device (CIED) related. Primary (or organic) TR results from an organic lesion of the tricuspid valve itself, whereas secondary (or functional) TR is caused by left-sided heart disease and/or pulmonary hypertension without an intrinsic abnormality of the tricuspid valve.[1] Secondary (functional) TR can be further classified according to the predominant mechanism and cardiac remodeling pattern into atrial secondary TR and ventricular secondary TR.[1] Atrial secondary TR is characterized by right atrial enlargement and tricuspid annular dilation with relatively preserved right ventricular size and function, whereas ventricular secondary TR is associated with right ventricular dilation, papillary muscle displacement, leaflet tethering, and often pulmonary hypertension.[1] TR in the presence of a CIED lead is classified as either CIED associated TR or CIED related TR. CIED associated TR is not directly caused by the lead while the CIED related TR is directly caused by lead placement.[1][2][3][4]
| Classification Etiologies |
|---|
| Primary/Organic TR |
| Degenerative Prolapse, flail
Congenital Ebstein anomaly, tricuspid atresia, leaflet cleft Acquired Infective endocarditis, rheumatic disease, carcinoid disease, traumatic, iatrogenic (biopsy, drugs, radiation therapy) |
| Secondary/Functional TR |
| Ventricular Secondary TR Primary pulmonary artery hypertension,
Pulmonary hypertension due to left heart diseases Pulmonary hypertension due to lung diseases Atrial Secondary TR Atrial fibrillation, heart failure with preserved ejection fraction |
| CIED-related TR |
| Type A (causative) Leaflet impingement, perforation,
Valvular/subvalvular adhesions/restriction Type B (incidental) No tricuspid valve interference |
Abbreviations: CIED, cardiac implantable electronic device; TR, tricuspid regurgitation
Based on severity, TR is expanded over a 5-grade scale.
| Mild (1+) | Moderate (2+) | Severe (3+) | Massive (4+) | Torrential (5+) | |
|---|---|---|---|---|---|
| Qualitative | |||||
| Tricuspid
Morphology |
Normal or mildly abnormal | Moderately abnormal | Severely abnormal (flail leaflet, large coaptation gap, marked tethering) | ||
| Color-flow jet area | Small, narrow, central | Moderate central | Large central, or eccentric, wall impinging | ||
| Flow convergence zone | Not visible, transient, or small | Intermediate in size and duration | Large throughout systole | ||
| CW-Doppler contour | Faint, partial,
parabolic |
Dense, parabolic | Dense, parabolic or
triangular |
Dense, often
triangular, may have low peak velocity |
Dense, usually triangular, often low peak velocity |
| Right heart size | Usually normal | Normal or mild
dilation |
Usually dilated | Dilated | |
| Semiquantitative | |||||
| VC width, mm | <3 | 3-6.9 | 7-13.9 | 14-20.9 | ≥21 |
| PISA radius, mm | ≤5.4 | 5.5-8.9 | ≥9 | ||
| Hepatic vein flow | Systolic dominant | Systolic blunting | Systolic flow reversal | ||
| Tricuspid inflow | A-wave dominant | Variable | E-wave dominant (≥1 m/s) | ||
| Quantitative | |||||
| PISA EROA, mm2 | <20 | 20-39 | 40-59 | 60-79 | ≥80 |
| Doppler volumetric | 75-94.9 | 95-114.9 | ≥115 | ||
| EROA, mm2 | |||||
| PISA RegVol, (mL) | <30 | 30-44 | 45-59 | 60-74 | ≥75 |
| RegFrac, % | <15 | 16-49% | ≥50 | ||
| 3D Vena contracta area, mm2 | 75-94.9 | 95-114.9 | ≥115 | ||
References
References
- ↑ 1.0 1.1 1.2 1.3 Hahn, R. T. (2023). Tricuspid regurgitation. The New England Journal of Medicine, 388(20), 1876–1891. https://doi.org/10.1056/NEJMra2216709
- ↑ Andreas, M., Burri, H., Praz, F., Soliman, O., Badano, L., Barreiro, M., Cavalcante, J. L., de Potter, T., Doenst, T., Friedrichs, K., Hausleiter, J., Karam, N., Kodali, S., Latib, A., Marijon, E., Mittal, S., Nickenig, G., Rinaldi, A., Rudzinski, P. N., … Leclercq, C. (2024). Tricuspid valve disease and cardiac implantable electronic devices. European Heart Journal, 45(5), 346–365. https://doi.org/10.1093/eurheartj/ehad783
- ↑ Antunes, M. J., Rodríguez-Palomares, J., Prendergast, B., De Bonis, M., Rosenhek, R., Al-Attar, N., Barili, F., Casselman, F., Folliguet, T., Iung, B., Lancellotti, P., Muneretto, C., Obadia, J.-F., Pierard, L., Suwalski, P., Zamorano, P., & on behalf of the ESC Working Groups of Cardiovascular Surgery and Valvular Heart Disease. (2017). Management of tricuspid valve regurgitation: Position statement of the European Society of Cardiology Working Groups of Cardiovascular Surgery and Valvular Heart Disease. European Journal of Cardio-Thoracic Surgery, 52(6), 1022–1030. https://doi.org/10.1093/ejcts/ezx279
- ↑ Hahn, R. T., Lawlor MD MS, M., Davidson, C. J., Badhwar, V., Sannino, A., Spitzer, E., Lurz, P., Lindman MD MSCI, B., Topilsky, Y., Baron MD MSc, S., Chadderdon, S., Khalique, O. K., Gilbert H.L. Tang, MD, MSc, MBA, Taramasso, M., Grayburn, P. A., Badano, L., Leipsic, J., Lindenfeld, J., Windecker, S., … Hausleiter, J. (2023). Tricuspid Valve Academic Research Consortium Definitions for Tricuspid Regurgitation and Trial Endpoints. Journal of the American College of Cardiology. https://doi.org/10.1016/j.jacc.2023.08.008
- ↑ 5.0 5.1 Tomaselli, M. (2025). New concepts regarding the pathophysiology, severity assessment and prognostic stratification of secondary tricuspid regurgitation using advanced echocardiography techniques. Italy.
- ↑ Hahn, R. T., & Zamorano, J. L. (2017). The need for a new tricuspid regurgitation grading scheme. European Heart Journal Cardiovascular Imaging, 18(12), 1342–1343. https://doi.org/10.1093/ehjci/jex139
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