Tricuspid regurgitation classification

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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]

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

The stages of TR can be estimated based on specific criteria for the valve anatomy, valve hemodynamics, associated cardiac findings, and symptoms.

2014 AHA/ACC Guidelines for Valvular Heart Diseases

Abbreviations: CW: continuous wave; ICD: implantable cardioverter-defibrillator; IE: infective endocarditis; IVC: inferior vena cava; RA: right atrium; RV: right ventricle; TR: tricuspid regurgitation

Stage	Definition	Valve anatomy	Valve hemodynamics	Hemodynamic consequences	Symptoms of TR, left heart failure, or pulmonary vascular disease
A	At risk of TR	Primary Mild rheumatic change Mild prolapse Findings related to other conditions (IE, carcinoid, radiation) Presence of an intra-annular RV pacemaker or ICD lead Cardiac transplant (biopsy-related) Secondary No abnormal findings Beginning of annular dilation	Absent or trace TR	Absent	Absent
B	Progressive TR	Primary Progressive leaflet deterioration/destruction Moderate-to-severe prolapse and limited chordal rupture Secondary Beginning of annular dilation Moderate leaflet tethering	Mild TR Central jet area <5.0 cm2 Undefined width of vena contracta Soft and parabolic CW jet density and contour Systolic dominance of hepatic vein flow Moderate TR Central jet area 5–10 cm2 Undefined width of vena contracta width but <0.70 cm Dense, variable CW jet density and contour Systolic blunting of hepatic vein flow	Mild TR Normal size of RV/RA/IVC Moderate TR Absence of RV enlargement Absent or mild RA enlargement Absent or mild IVC enlargement with normal respirophasic variation Normal RA pressure	Absent
C	Asymptomatic severe TR	Primary Flail or grossly distorted leaflets Secondary Severe annular dilation (>40 mm or 21 mm/m2) Marked leaflet tethering	* Central jet area >10.0 cm 2* Vena contracta width >0.7 cm Dense, triangular CW jet density and contour with early peak Systolic reversal in hepatic vein flow	* Dilated RV/RA/IVC and decreased IVC respirophasic variation Increased RA pressure with “c-V” wave Possible diastolic interventricular septal flattening	Absent
D	Symptomatic severe TR	Primary Flail or grossly distorted leaflets Secondary Severe annular dilation (>40 mm or 21 mm/m2) Marked leaflet tethering	* Central jet area >10.0 cm2 Vena contracta width >0.7 cm Dense, triangular CW jet density and contour with early peak Systolic reversal in hepatic vein flow	* Dilated RV/RA/IVC and decreased IVC respirophasic variation Increased RA pressure with “c-V” wave Possible diastolic interventricular septal flattening	Presence of symptoms (fatigue, dyspnea, anorexia, edema, abdominal distention, palpitations)