Tricuspid valve regurgitation

Etiologic Classification of TR

Primary TR

Degenerative (prolapse, flail)
Infective endocarditis
Trauma to the chest wall or leaflets
Ebstein anomaly
Carcinoid disease
Mediastinal radiation
Rheumatic disease

Secondary TR

Ventricular secondary TR

Pulmonary hypertension due to
- gr I PAH
- gr II Left-sided heart disease or left-sided valve disease
- gr III Chronic lung disease
- gr IV CTEPH
- Intracardiac shunt

Atrial secondary TR

HFpEF
Atrial arrhythmia

CIED-related TR

CIED-related causative TR
- Direct interaction of the lead with the TV leaflets or sub-valvular apparatus
CIED-related incidental TR
- CIED present but not the direct cause of TR

Carpentier classification

Carpentier type I: Normal leaflet motion

example: IE,

Atrial secondary TR

TV Tethering +/-
RA/TA dilatation ++++
RV dilatation +/-
RV dysfunction +/-
Conical RV remodelling

Carpentier type II: Excess leaflet motion

example: TV prolapse

TV tethering -
RA/TA dilatation ++
RV dilatation +/-
RV dysfunction +/-
Leaflet restriction -

Carpentier type III: Restrict leaflet motion

Type IIIa

example: Rheumatic TR,

CIED-related (leaflet adhesion)

TV Tethering -

RA TA dilatation +++

RV dilatation +/-

RV dysfunction +/-

Leaflet restriction diastole

Type IIIb

example: Ventricular secondary TR

TV Tethering ++++

RA dilatation ++

RV dilatation +++

RV dysfunction +++

Leaflet restriction systole

Elliptical RV remodelling

Mechanisms of CIED lead-induced TR

1) direct leaflet impingement

2) lead entanglement in the subvalvular apparatus

3) leaflet or papillary muscle perforation

4) lead adherence or laceration causing scarring and fibrosis of any tricuspid apparatus in the path of the lead

5) RV pacing-induced dyssynchrony resulting in annular dilatation and remodeling

6) thromboembolism from leads resulting in pulmonary hypertension

Expanded TR Grading Severity Scale

Variable	Mild	Moderate	Severe	Massive	Torrential
VC (mm)	< 3	3 - 6.9	7 - 13.9	14 - 20.9	≥ 21
PISA EROA (mm²)	< 20	20 - 39	40 - 59	60 - 79	≥ 80
3D VCA (mm²)			75 - 94.9	95 - 114.9	≥ 115

Tricuspid Valve Academic Research Consortium Proposed Echocardiographic Cutoffs for
RV Function

Variable	Mild dysfunction	Moderate dysfunction	Severe dysfunction
TAPSE (mm)	14 - 17	10 - 13	< 10
RV s′ velocity (cm/s)	9 - 11	6 - 8	< 6
RV GLS (%)	18 - 21	14 - 17	< 14
RV FWS (%)	20 - 23	15 - 19	< 15
FAC (%)	34 - 37	30 - 33	< 30
3D RV EF (%)	45 - 50	35 - 45	< 35

References

O’Gara, P, Lindenfeld, J, Hahn, R. et al. 10 Issues for the Clinician in Tricuspid Regurgitation Evaluation and Management: 2025 ACC Expert Consensus Decision Pathway: A Report of the American College of Cardiology Solution Set Oversight Committee. JACC. 2026 Feb, 87 (4) 447–486. https://doi.org/10.1016/j.jacc.2025.07.002

Hahn RT, Lawlor MK, Davidson CJ, Badhwar V, Sannino A, Spitzer E, et al. Tricuspid Valve Academic Research Consortium Definitions for Tricuspid Regurgitation and Trial Endpoints. Journal of the American College of Cardiology [Internet]. 2023 Oct 24;82(17):1711–35. Available from: https://www.sciencedirect.com/science/article/pii/S0735109723064033