Table 2.
Classification of TR by Cause and Presenting Abnormalities
| Causative Disease Process | Etiology | Tricuspid Valve/RV Morphology | Carpentier Classification |
|---|---|---|---|
| Primary TR (5%-10% of patients) | |||
| Degenerative disease | Prolapse or flail leaflet | Abnormal leaflet mobility, normal RV | II |
| Congenital | Apical displacement of leaflet attachment (ie, Ebstein's anomaly) | Abnormal leaflet position, atrialized RV | I or IIIb |
| Acquired (ie, tumors, trauma, carcinoid, RHD, radiation) | Leaflet Injury (ie, tumor, trauma, biopsy, lead extraction) or infiltration/fibrosis (ie, carcinoid, rheumatic disease, radiation valvulopathy) | Abnormal leaflet morphology/mobility, normal RV | I or IIIa |
| Secondary TRa (∼80% of patients) | |||
| Ventricular secondary TR | |||
| Left ventricular disease | Postcapillary PH (HFpEF, HFrEF) | RV dilatation (spherical remodeling)/dysfunctional → leaflet tethering, dilated RA/TA | I or IIIb |
| Left heart valvular disease | Postcapillary PH | I or IIIb | |
| Pulmonary disease | Precapillary PH (chronic lung disease, CTEPH, PAH) | I or IIIb | |
| RV dysfunction/remodeling | RV dilatation and dysfunction (ie, RV infarct, RV dysplasia) | IIIb | |
| Atrial secondary TR | |||
| RA/TA dilatationa | RA/TA dilatation (ie, related to age, atrial fibrillation, HFpEF) | RA dilatation/dysfunction → TA dilatation (minimal leaflet tethering), conical RV remodeling | I |
| CIED-related TR (∼10%-15%) | |||
| LTR-A (causative) | Leaflet impingement, perforation, valvular/subvalvular adhesions/restriction | Tricuspid leaflet tethering/adhesions | I or IIIb |
| LTR-B (incidental)b | CIED present without tricuspid valve apparatus interference | Morphology dependent on primary disease process | I, II, or III |
CIED = cardiovascular implantable electronic device; CTEPH = chronic thromboembolic pulmonary hypertension; HFpEF = heart failure with preserved ejection fraction; HFrEF = heart failure with reduced ejection fraction; LTR = lead-related tricuspid regurgitation; PAH = pulmonary arterial hypertension; PH = pulmonary hypertension; RA = right atrial; RHD = rheumatic heart disease; RV = right ventricular; TA = tricuspid annular; TR = tricuspid regurgitation.
aChronic TR may result in RV remodeling with subsequent leaflet tethering.
bCIED may be present and although not the causative mechanism of tricuspid regurgitation, may impact transcatheter device choice.