MioAtlas
G2: Right-sided valves

Functional tricuspid regurgitation

Incompetence of the tricuspid valve secondary to right ventricular dilation and/or tricuspid annular dilation and leaflet tethering, without intrinsic structural alterations of the valve leaflets.

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Definition

Tricuspid valve regurgitation due to right ventricular dilation and dysfunction and/or tricuspid annular dilation (secondary to pulmonary hypertension, right ventricular pressure/volume overload, or atrial/ventricular cardiomyopathy), in the presence of anatomically normal tricuspid leaflets with systolic tethering and loss of coaptation surface [V1] [V3] [G23-01] [G23-02].

Severity criteria

  • Mild (L): vena contracta (VC) < 3 mm; PISA radius ≤ 5 mm (at Nyquist baseline shift velocity of 28 cm/s); Effective regurgitant orifice area (EROA) < 0.20 cm²; Regurgitant volume (RV) < 30 mL/beat; Continuous-wave Doppler: faint or incomplete jet; preserved systolic forward flow in hepatic veins [V1] [V3] [G23-01] [G23-02].
  • Moderate (M): VC 3.0–6.9 mm; PISA radius 6–9 mm; EROA 0.20–0.39 cm²; RV 30–44 mL/beat; Continuous-wave Doppler: dense parabolic jet; blunting of systolic forward flow in hepatic veins [V1] [V3] [G23-01] [G23-02].
  • Severe (G): VC ≥ 7.0 mm; PISA radius > 9 mm; EROA ≥ 0.40 cm²; RV ≥ 45 mL/beat; Systolic flow reversal in hepatic veins; Continuous-wave Doppler: dense triangular holosystolic signal with early velocity peaking (v-wave cut-off sign) due to rapid RV-RA pressure equalization [V1] [V3] [G23-01] [G23-02]. (Clinical note: Contemporary 5-grade classifications also include massive with VC ≥ 14 mm, EROA ≥ 0.60 cm² and torrential with VC ≥ 21 mm, EROA ≥ 0.80 cm² [G23-01]).

Findings by layer

Hemodynamics

  • Mean right atrial pressure markedly elevated in severe forms (G: 10–18 mmHg) with diastolic pressure equalization with the RV [V1] [G23-01].
  • Right ventricular volume overload with markedly increased right ventricular end-diastolic volume [V1] [V3].

Rhythm

  • Atrial fibrillation very frequent as both cause and consequence of tricuspid annular and right atrial dilation [V1] [G23-01].
  • Normal sinus rhythm in initial stages [V1].

ECG

  • Right atrial enlargement (P pulmonale, peaked P wave > 2.5 mm in inferior leads in sinus rhythm) [E1].
  • Right ventricular strain or hypertrophy (right ventricular hypertrophy) and incomplete right bundle branch block [E1] [E2].

Heart sounds and murmurs

  • Holosystolic regurgitant murmur: Plateau systolic murmur auscultated at the 4th–5th left intercostal space at the lower left sternal border (LLSB), typically increasing in intensity with inspiration (Rivero-Carvallo sign) [B1] [G1-14].
  • Right-sided third heart sound (S3): Right ventricular rapid filling third sound at LLSB that increases with inspiration in severe volume overload [G1-12].
  • Second heart sound (S2): Accentuated pulmonary component (P2) if pulmonary hypertension coexists [G1-11] [C7].

Arterial pulse

  • Peripheral arterial pulse normal or decreased in volume (parvus) in advanced stages with low forward cardiac output [B4].

Jugular venous pulse

  • Jugular venous distention with giant 'cv' wave (giant v wave / cv wave) obliterating the systolic x descent, and steep, deep 'y' descent (steep y descent) [B3].

Maneuvers

  • Deep inspiration (Rivero-Carvallo sign): Markedly increases acoustic intensity of the tricuspid systolic murmur due to increased venous return to right-sided chambers [B1].
  • Valsalva maneuver (strain phase): Decreases murmur intensity; upon release, the tricuspid murmur recovers immediately within the first 1–2 beats [B1].
  • Hepatic compression (hepatojugular reflux): Increases venous return and accentuates the murmur and the cv wave [B1] [B3].

Simulator severity grades

Simulator severity grades: Mild, Moderate, Severe
Baseline rhythm: Normal Sinus Rhythm

Also known as: Functional tricuspid regurgitation · Secondary tricuspid regurgitation · Tricuspid insufficiency · Functional TR · TR

Other pathologies in this group

Sources

  1. [B1] Bedside diagnosis of systolic murmurs . N Engl J Med (1988) . DOI: 10.1056/NEJM198806163182404 PubMed: 2897627
  2. [B3] The jugular venous pressure revisited . Cleve Clin J Med (2013) . DOI: 10.3949/ccjm.80a.13039 PubMed: 24085809
  3. [B4] The Carotid Pulse . Clinical Methods: The History, Physical, and Laboratory Examinations (1990) . PubMed: 21250154
  4. [C7] 2022 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension . Eur Heart J (2022) . DOI: 10.1093/eurheartj/ehac237 PubMed: 36017548
  5. [E1] AHA/ACCF/HRS recommendations for the standardization and interpretation of the electrocardiogram: part V: electrocardiogram changes associated with cardiac chamber hypertrophy: a scientific statement from the American Heart Association Electrocardiography and Arrhythmias Committee, Council on Clinical Cardiology; the American College of Cardiology Foundation; and the Heart Rhythm Society: endorsed by the International Society for Computerized Electrocardiology . Circulation (2009) . DOI: 10.1161/CIRCULATIONAHA.108.191097 PubMed: 19228820
  6. [E2] AHA/ACCF/HRS recommendations for the standardization and interpretation of the electrocardiogram: part III: intraventricular conduction disturbances: a scientific statement from the American Heart Association Electrocardiography and Arrhythmias Committee, Council on Clinical Cardiology; the American College of Cardiology Foundation; and the Heart Rhythm Society: endorsed by the International Society for Computerized Electrocardiology . Circulation (2009) . DOI: 10.1161/CIRCULATIONAHA.108.191095 PubMed: 19228822
  7. [G1-10] The First Heart Sound . Clinical Methods: The History, Physical, and Laboratory Examinations (1990) . PubMed: 21250175
  8. [G1-11] The Second Heart Sound . Clinical Methods: The History, Physical, and Laboratory Examinations (1990) . PubMed: 21250183
  9. [G1-12] The Third Heart Sound . Clinical Methods: The History, Physical, and Laboratory Examinations (1990) . PubMed: 21250184
  10. [G1-14] Systolic Murmurs . Clinical Methods: The History, Physical, and Laboratory Examinations (1990) . PubMed: 21250186
  11. [G23-01] Tricuspid regurgitation: recent advances in understanding pathophysiology, severity grading and outcome . Eur Heart J Cardiovasc Imaging (2022) . DOI: 10.1093/ehjci/jeac009 PubMed: 35157070
  12. [G23-02] European Association of Echocardiography recommendations for the assessment of valvular regurgitation. Part 2: mitral and tricuspid regurgitation (native valve disease) . Eur J Echocardiogr (2010) . DOI: 10.1093/ejechocard/jeq031 PubMed: 20435783
  13. [V1] 2025 ESC/EACTS Guidelines for the management of valvular heart disease . Eur Heart J (2025) . DOI: 10.1093/eurheartj/ehaf194 PubMed: 40878295
  14. [V3] Recommendations for Noninvasive Evaluation of Native Valvular Regurgitation: A Report from the American Society of Echocardiography Developed in Collaboration with the Society for Cardiovascular Magnetic Resonance . J Am Soc Echocardiogr (2017) . DOI: 10.1016/j.echo.2017.01.007 PubMed: 28314623