Table 4.

Echocardiographic Parameters and Relative Cutoffs for TR 5-Tier Grading

	Mild (1+)	Moderate (2+)	Severe (3+)	Massive (4+)	Torrential (5+)
Qualitative
Tricuspid morphology	Normal or mildly abnormal	Moderately abnormal	Severely abnormal (flail leaflet, large coaptation gap, marked tethering)
Color-flow jet area	Small, narrow, central	Moderate central	Large central, or eccentric, wall impinging
Flow convergence zone	Not visible, transient, or small	Intermediate in size and duration	Large throughout systole
CWD contour	Faint, partial, parabolic	Dense, parabolic	Dense, parabolic or triangular	Dense, often triangular, may have low peak velocity	Dense, usually triangular, often low peak velocity
Right heart dimensions	Usually normal	Normal or mild dilatation	Usually dilated	Dilated
Semiquantitative
VCW (biplane), mma	<3	3–6.9	7–13.9	14–20.9	≥21
PISA radius, mmb	≤5.4	5.5–8.9	≥9
Hepatic vein flowc	Systolic dominant	Systolic blunting	Systolic flow reversal
Tricuspid inflow (PWD)	A-wave dominant	Variable	E-wave dominant (≥1 m/s)
Quantitative
PISA EROA, mm2	<20	20–39	40–59	60–79	≥80
Regurgitant volume (2D PISA), mL	<30	30–44	45–59	60–74	≥75
New quantitative methods
Regurgitant fraction, %	≤15	16–49	≥50
3D VCA, mm2	—	—	75–94.9	95–114.9	≥115
2D Doppler EROA, mm2	—	—	75–94.9	95–114.9	≥115

CWD = continuous-wave Doppler; EROA = effective regurgitant orifice area; PISA = proximal isovelocity surface area; PWD = pulsed-wave Doppler; VCA = vena contracta area; VCW = vena contracta width; other abbreviations as in Table 3.

^aAt a color Doppler scale between 40 and 60 cm/s. Note that some studies suggest an average VCW of >9 mm should define severe TR.

^bColor Doppler Nyquist shift down toward 20 cm/s, until the hemispherical flow convergence zone is clearly visualized.

^cUnless other reason for flow reversal (ie, atrial fibrillation, right atrial elevated pressures/noncompliance). Adapted from: 1) Zoghbi et al¹⁶; 2) Lancellotti et al⁸; and 3) Hahn et al.¹⁹