Tricuspid regurgitation stages

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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]

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Overview

The stage of tricuspid regurgitation (TR) can be estimated based on specific criteria for the valve anatomy, valve hemodynamics, associated cardiac findings, and symptoms. The stages of TR are the following: at risk of TR, progressive TR, asymptomatic severe TR, and symptomatic severe TR.[1]

Stages

2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines[2]

Stages of TR

Stage Definition Valve hemodynamics Hemodynamic consequences Clinical Symptoms and Presentation
B Progressive TR
  • Central jet <50% RA
  • Vena contracta width <0.7 cm
  • ERO <0.40 cm2
  • Regurgitant volume <45 mL
None None
C Asymptomatic severe TR
  • Central jet ≥50% RA
  • Vena contracta width ≥0.7 cm
  • ERO ≥0.40 cm2Regurgitant volume ≥45 mL
  • Dense continuous wave signal with triangular shape
  • Hepatic vein systolic flow reversal
  • Dilated RV and RA
  • Elevated RA with “c-V” wave
  • Elevated venous pressure
  • No symptoms
D Symptomatic severe TR Central jet ≥50% RA

Vena contracta width ≥0.7 cm

ERO ≥0.40 cm2Regurgitant volume ≥45 mL

Dense continuous wave signal with triangular shape

Hepatic vein systolic flow reversal

  • Dilated RV and RA
  • Elevated RA with “c-V” wave
  • Elevated venous pressure
  • Dyspnea on exertion, fatigue, ascites, edemac-V wave indicates systolic positive wave; ERO, effective regurgitant orifice; RA, right atrial; RV, right ventricular; and TR, tricuspid regurgitation.






Shown below is a table depicting the stages of TR adapted from the 2014 AHA/ACC guidelines for management of valvular heart disease.[1]

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

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

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

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)

References

  1. 1.0 1.1 Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA; et al. (2014). "2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines". Circulation. doi:10.1161/CIR.0000000000000029. PMID 24589852.
  2. Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F; et al. (2021). "2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines". Circulation. 143 (5): e72–e227. doi:10.1161/CIR.0000000000000923. PMID 33332150 Check |pmid= value (help).


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