|TV morphology||Normal or mildly abnormal leaflets||Usually abnormal leaflets||Severe valve lesions (e.g., Flail leaflet, severe tethering, malcoaptation)|
|Interventricular septal motion||Normal||Typically normal||Paradoxical/volume overload pattern (diastolic interventricular septal flattening)|
|Color flow TR jet (note: not recommended for sole grading of severity)||Small RA penetration or not holosystolic||Moderate RA penetration or large penetration and late systolic||Deep RA penetration and holosystolic jet, or eccentric wall-impinging jet (variable size)|
|Flow convergence zone||Not visible, transient or small||Intermediate in size and duration||Large throughout systole|
|CW TR jet density/contour||Faint/parabolic or partial contour||Dense, variable contour||Dense, triangular with early peaking contour|
|IVC size||Usually normal||Usually normal or mild dilation||Usually dilated∗ with reduced respirophasic variability|
|RV and RA size||Usually normal||Usually normal or mild dilation||Usually dilated†|
|Tricuspid annulus||<40 mm2 or 21 mm2/m2||May be >40 mm2 or 21 mm2/m2||>40 mm2 or 21 mm2/m2|
|Color flow jet area (cm2) [central jet]‡||Not defined||Not defined but <10||>10|
|Vena contracta (cm)‡||Not defined||Not defined but <0.7||≥0.7|
|PISA radius (cm)§||≤0.5||0.6–0.9||>0.9|
|Hepatic vein flow||Systolic dominance||Systolic blunting‖||Systolic flow reversal|
|Tricuspid inflow||A-wave dominant and/or E-wave <1 m/s||Variable||E-wave dominant and ≥1.0 m/s|
|EROA (mm2) [by PISA]||<20||20–39¶||≥40|
|Regurgitant volume (ml) [by PISA]||<30||30–45¶||≥45|
Assessment of TR severity is by a combination of the American Society of Echocardiography and European Society of Echocardiography Recommendations for the Assessment of Valvular Regurgitation (30,31) and the AHA/ACC Guideline (15). Bolded signs are considered specific of their TR grade.
CW = continuous wave; EROA = effective regurgitant orifice area; RA = right atrium; RV = right ventricular; TR = tricuspid regurgitation; TV = tricuspid valve; other abbreviations as in Table 1.
↵∗ IVC diameter of >2.5 cm as per ASE guidelines (30).
↵† RV and RA can be within the ”normal“ range for patients with acute severe TR or with chronic severe TR associated with restrictive cardiomyopathy.
↵‡ At a Nyquist limit = 50-60 cm/s.
↵§ With Baseline Nyquist limit shift of 28 cm/s.
↵‖ Signs are non-specific and are influenced by many other factors (RV diastolic function, atrial fibrillation, RA pressure).
↵¶ There is little data to support further separation of these values.