Staging of Tricuspid Regurgitation

Classification and Staging

The American College of Cardiology and American Heart Association establish a four-stage classification system (A through D) for tricuspid regurgitation, guiding surveillance and intervention timing 1
Stage A patients have risk factors for tricuspid regurgitation but no or only trace regurgitation present, with primary risk factors including mild rheumatic valve changes, mild leaflet prolapse, infective endocarditis, early carcinoid deposition, radiation exposure, intra-annular RV pacemaker or ICD leads, and post-cardiac transplant damage 1, 2

Patients with mild-to-moderate tricuspid regurgitation and early structural changes remain asymptomatic, with valve anatomy changes including progressive leaflet deterioration, moderate-to-severe prolapse, and early annular dilation 1, 2
Hemodynamic parameters for mild tricuspid regurgitation include a central jet area <5.0 cm², soft parabolic continuous wave jet density, and hepatic vein flow showing systolic dominance 1
Hemodynamic parameters for moderate tricuspid regurgitation include a central jet area of 5-10 cm², vena contracta width <0.70 cm, and hepatic vein flow showing systolic blunting 1, 2

Patients have severe tricuspid regurgitation by echocardiographic criteria but no symptoms attributable to right heart failure, with valve anatomy changes including flail or grossly distorted leaflets and severe annular dilation 1, 2
Hemodynamic parameters include a central jet area >10.0 cm², vena contracta width >0.7 cm, and hepatic vein flow showing systolic reversal 1, 2

Patients have severe tricuspid regurgitation with symptoms of right heart failure, including fatigue, palpitations, dyspnea, abdominal bloating, anorexia, and peripheral edema 1, 2, 3
The American College of Cardiology recommends tricuspid valve surgery for patients with severe tricuspid regurgitation (Stage D) at the time of left-sided valve surgery, with concomitant tricuspid repair considered when tricuspid annular diameter is ≥40 mm (or ≥21 mm/m²) 1, 4

Surveillance strategies vary by stage, with monitoring for progression of risk factors in Stage A, serial echocardiography in Stage B, close monitoring in Stage C, and urgent surgical evaluation in Stage D 1
Intervention timing is critical, with tricuspid valve surgery recommended for patients with severe tricuspid regurgitation (Stage D) at the time of left-sided valve surgery 1, 4