Tricuspid regurgitation grading (five grades)
TR VC, EROA, 3D VCA · RV-focused A4C and PSAX inflow colour; PISA; 3D vena contracta area
Normal range & thresholds
| Grade | VC (biplane, mm) | EROA (PISA, mm²) | 3D VCA (mm²) |
|---|---|---|---|
| Mild | <3 | <20 | — |
| Moderate | 3–6.9 | 20–39 | — |
| Severe | 7–13 | 40–59 | 75–94 |
| Massive | 14–20 | 60–79 | 95–114 |
| Torrential | ≥21 | ≥80 | ≥115 |
Adopted by the 2025 ESC/EACTS guideline and TVARC [6,81,183].
Pathophysiology
Most TR is secondary — atrial (annular dilatation in AF/HFpEF) or ventricular (RV dilatation and leaflet tethering in PH or left-heart disease). Beyond ‘severe’, the extra grades separate patients with different outcomes and transcatheter options; mortality rises with each grade in community cohorts [184,81].
Raised by
- AF and atrial cardiopathy, PH, left-heart disease, pacing leads, RV cardiomyopathy, carcinoid, endocarditis, Ebstein
Lowered by
- Decongestion and rhythm control reduce secondary TR
Technique & pitfalls
- Grade euvolaemic; biplane VC; PISA with low Nyquist; hepatic vein flow (card 74); RV size and function; PASP [3,104].
Pseudo-change & artefact
- Torrential TR lowers the Doppler velocity (laminar, early-peaking) — PASP underestimated.
Treatment thresholds
- Severe TR at left-sided surgery → concomitant repair; isolated severe symptomatic TR → surgery or transcatheter therapy in selected patients; severe RV dysfunction and precapillary PH exclude transcatheter therapy [6]; TEER improved quality of life (TRILUMINATE) [65].
Next step
- RV function, PH work-up, lead assessment, CMR RV volumes.
Drugs
Diuretics; rhythm control in atrial TR.
Reversibility
Atrial TR can regress with sinus rhythm.