JACC: CARDIOVASCULAR IMAGING VOL. 12, NO.

3, 2019

ª 2019 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION

PUBLISHED BY ELSEVIER

STATE-OF-THE-ART PAPER

Imaging Assessment of
Tricuspid Regurgitation Severity
Rebecca T. Hahn, MD,a James D. Thomas, MD,b Omar K. Khalique, MD,a João L. Cavalcante, MD,c
Fabien Praz, MD,a,d William A. Zoghbi, MDe

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Author Disclosures: Dr. Hahn is the Chief Scientific Officer for the Echo-
cardiography Core Laboratory at the Cardiovascular Research Foundation
for which she receives no direct industry compensation; and has received
personal fees from Abbott Vascular, Boston Scientific, Bayliss, Navigate,
Philips Healthcare, and Siemens Healthineers. Dr. Thomas is a consultant
for and receives honoraria from Edwards Lifesciences, Abbott, GE
Healthcare, and Bay Labs; and his spouse is an employee of Bay Labs. Dr.
Khalique is a member of the Speakers Bureau for Edwards Lifesciences; and
is a consultant for Cephea Valves and Jenavalve. Dr. Cavalcante is a
consultant for Medtronic and Mitralign; and has received research support
from Medtronic, Siemens and Circle CVI. Dr. Praz is a consultant for
Edwards Lifesciences. All other authors have reported that they have no
relationships relevant to the contents of this paper to disclose.

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From the aNew York-Presbyterian/Columbia University Irving Medical Center, New York, New York; bBluhm Cardiovascular
c
Institute, Northwestern Medicine, Northwestern University, Chicago, Illinois; Minneapolis Heart Institute, Abbott
Northwestern Hospital, Minneapolis, Minnesota; dDepartment of Cardiology, University Hospital Bern, Bern, Switzerland; and
the eHouston Methodist DeBakey Heart & Vascular Center, Houston, Texas. Dr. Hahn is the Chief Scientific Officer for the
Echocardiography Core Laboratory at the Cardiovascular Research Foundation for which she receives no direct industry
compensation; and has received personal fees from Abbott Vascular, Boston Scientific, Bayliss, Navigate, Philips Healthcare, and
Siemens Healthineers. Dr. Thomas is a consultant for and receives honoraria from Edwards Lifesciences, Abbott, GE Healthcare,

ISSN 1936-878X/$36.00 https://doi.org/10.1016/j.jcmg.2018.07.033

470 Hahn et al. JACC: CARDIOVASCULAR IMAGING, VOL. 12, NO. 3, 2019

TR Assessment MARCH 2019:469–90

Imaging Assessment of
Tricuspid Regurgitation Severity
Rebecca T. Hahn, MD,a James D. Thomas, MD,b Omar K. Khalique, MD,a João L. Cavalcante, MD,c Fabien Praz, MD,a,,d
William A. Zoghbi, MDe

SUMMARY

Assessing the severity of tricuspid regurgitation remains a challenging task, and although echocardiography is the test of
choice, significant limitations of the current recommendations exist. Newer methods have been used in current trials of
transcatheter devices and may improve our understanding of the disease process. Cardiac magnetic resonance imaging and
computed tomography angiography may play significant roles as adjunctive imaging modalities. This paper reviews the
imaging modalities currently used to quantify tricuspid regurgitation severity. (J Am Coll Cardiol Img 2019;12:469–90)
© 2019 by the American College of Cardiology Foundation.

A ssessing the severity of tricuspid regurgita-

tion (TR) remains a challenging task, and
although echocardiography is the test of
choice, significant limitations of the current recom-
mendations exist (1). Recently updated guidelines
from the American Society of Echocardiography sug-
gest cardiac magnetic resonance (CMR) imaging and
computed tomography angiography (CTA) may play
a significant role. Even more challenging is the quan-
tification of TR following surgical or transcatheter
repair devices. This paper reviews the imaging mo-
dalities currently used to quantify native TR severity
and comments on the applicability of these methods
to post-device assessment. General strengths and
weaknesses of each imaging modality are presented
in Table 1. The Central Illustration summarizes the
complementary nature and relative clinical utility of
the imaging modalities specifically for assessment of
TR severity.
RECOMMENDED AND NOVEL
ECHOCARDIOGRAPHIC APPROACHES TO
EVALUATE TRICUSPID REGURGITATION
Although most Doppler methods used to characterize
left-sided valvular regurgitation (jet size, vena con-
tracta [VC] width, proximal convergence analysis,
volumetric quantitation, and other characteristics)
are directly applicable when assessing the severity of
TR, there are some important distinctions that must
be borne in mind. Chief among these differences is
that the TR jet is usually a lower pressure/lower ve-
locity than is typically found in mitral regurgitation.
Except at the extremes of pulmonary hypertension,
where pulmonary artery pressures equal systemic
pressure, the right ventricular systolic pressures will
be less than the systemic arterial pressures, and this
impacts proximal convergence, volumetric, and jet
analysis (2,3).
COLOR DOPPLER JET AREA. The relationship be-
tween TR jet size and regurgitant severity is governed
by the fluid dynamics of turbulent jets, a detailed
exposition of which can be found in Thomas et al. (4)
and is summarized in the present paper.
Generally, fluid flow inside the heart (or anywhere)
is governed by conservation of mass, momentum, and
energy. Echocardiographers are familiar with conser-
vation of mass (the continuity equation) and energy
(the Bernoulli equation), but jet flow (and thus color
Doppler jet area) is governed mainly by conservation
of momentum (generally defined as flow
velocity).
For a jet originating through a regurgitant orifice with
an effective regurgitant orifice area (EROA) of A and a
velocity of v, the following should be true: [flow (Q) ¼
A
v] and [momentum (M) ¼ Q
v or A
v2 ].
For the same EROA, a 5 m/s jet (i.e., a mitral
regurgitant jet) will have 4 times the color jet area as a
2.5 m/s jet (i.e., TR jet). Hence, if a color jet area is the

and Bay Labs; and his spouse is an employee of Bay Labs. Dr. Khalique is a member of the Speakers Bureau for Edwards Life-
sciences; and is a consultant for Cephea Valves and Jenavalve. Dr. Cavalcante is a consultant for Medtronic and Mitralign; and has
received research support from Medtronic, Siemens and Circle CVI. Dr. Praz is a consultant for Edwards Lifesciences. All other
authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Manuscript received June 6, 2018; revised manuscript received July 24, 2018, accepted July 25, 2018.
JACC: CARDIOVASCULAR IMAGING, VOL. 12, NO. 3, 2019 Hahn et al. 471
MARCH 2019:469–90 TR Assessment

only assessment of severity, echocardiographers physical factor determining color Doppler jet ABBREVIATIONS

would need to adjust their criteria for understanding size is its momentum, which is typically AND ACRONYMS

the influence of jet momentum. lower for TR and mitral regurgitation

2D = 2-dimensional
Several other factors also impact jet size by color (Figure 1); 2) reducing the scale also reduces
AROA = anatomic regurgitant
Doppler besides jet momentum. First, a number of the minimal velocity detected, which makes orifice area
instrument settings critically alter the displayed jet, the jet appear larger (Figure 2); 3) regurgitant
CMR = cardiac magnetic
roughly divided into factors that impact sensitivity to jets can be reduced in size due to chamber resonance imaging
low amplitude (weak) Doppler signals, such as power, constraint, especially jets that are directed CTA = computed tomography
gain, and the tissue priority setting, and those that eccentrically into an adjacent wall (Figure 3); angiography

affect the display of low-velocity signals at the pe- and 4) multiple views are necessary, and CW = continuous wave
riphery of jets (5). Chief among these is the color scale images need to be optimized for adequate TR EROA = effective regurgitant
that sets the upper limit that color Doppler can jet visualization. orifice area

display without aliasing but also affects the minimum Despite these limitations, jet area has been PC = phase-contrast

velocity encoded, typically a value 5% to 10% of the associated with poor outcomes in the surgical PISA = proximal isovelocity
aliasing velocity. When the scale is lowered, lower repair population. Severe TR, defined as a jet surface area

velocity jet signals appear, and the jet gets larger. area >10 cm 2, after tricuspid valve repair or PW = pulsed wave

Other machine settings that can impact these low bioprosthetic valve replacement was a signif- RA = right atrium

velocities are the wall filter and the transducer fre- icant predictor of poor event-free survival, TR = tricuspid regurgitation
quency (6). Jet size is also affected by constraint of even after adjustment for pre-operative risk va = aliasing velocity
the right atrium (RA) and eccentric “wall” jets that are factors (p ¼ 0.036) (9). A ratio of jet area to RA Vmax = maximum tricuspid
directed against the RA. Wall jets are, on average, 75% area of $34% was shown by both thermodi- regurgitation velocity

smaller than central jets of similar severity (7).
In vitro studies have also shown significantly smaller
color Doppler jets due to the Coanda effect, where jets
are attracted to an adjacent parallel structure which,
for TR, is the interatrial septum (8).
Thus, the key issues to keep in mind when viewing
TR color Doppler jets are: 1) the most important
lution techniques (10) and open surgical VC = vena contracta
techniques (11) to suggest severe TR. Because VCA = vena contracta area
RA size itself has been directly correlated with TR
severity (12), particularly in patients with atrial fibril-
lation (13,14) a fixed %RA area ratio would tend to
underestimate the severity with progressive enlarge-
ment of this chamber.

T A B L E 1 Advantages and Disadvantages of Each Imaging Modality Used for the Assessment of Tricuspid Valve Function

Modality Advantages Disadvantages

Echocardiography Readily available and portable 3D acquisition and interpretation requires more skill
Transthoracic and transesophageal approaches Transesophageal echo is semi-invasive, and sedation is typically required
Multiplane 2D and 3D real-time imaging Limitations of ultrasonography physics (i.e., acoustic shadowing, lateral
No iodinated intravenous contrast resolution, far-field imaging, 3D volume rates, and so forth)
No radiation Incomplete vascular assessment
Excellent temporal resolution and good spatial resolution
Functional and hemodynamic information
Automated post-processing tools (becoming more available)
Cardiac magnetic Good temporal and spatial resolution Spatial resolution is inferior to computed tomography angiography and
resonance Minimal effect of body habitus echocardiography (thick slices)
Gold standard for ventricular volumes, mass and ejection fraction Lower temporal resolution than echocardiography
(no contrast required) Requires adequate training for comprehensive examination acquisition and
Excellent for valvular regurgitation (no contrast) interpretation
Excellent myocardial tissue characterization Longer examination (free breathing examination is possible)
No radiation and noninvasive Claustrophobia
Can assess anatomy without intravenous gadolinium Incompatible with certain intracardiac devices (e.g., intracardiac
Vascular assessment cardioverter- defibrillator, cardiac resynchronization therapy, older
Hemodynamic information permanent pacemakers)
Suboptimal quantification can occur with fast and irregular cardiac rhythms
(unless newer pulse sequences are available)
Cannot visualize calcification well
Peak velocities may be underestimated
Computed tomography Excellent spatial resolution (gold standard for anatomical Frequently requires iodinated intravenous contrast (elevated risk in patients
angiography information and structural planning) with chronic kidney dysfunction)
Noninvasive and fast Radiation dose has improved but is high in 4D (functional) imaging
Extensive training not required Poor temporal resolution (better with dual-source imaging)
Automated post-processing tools are available with Suboptimal with fast and irregular cardiac rhythms
comprehensive vascular assessment Not portable
Blooming artifacts can occur with calcium, valve stent frames, intracardiac
leads, and others
472 Hahn et al. JACC: CARDIOVASCULAR IMAGING, VOL. 12, NO. 3, 2019

TR Assessment MARCH 2019:469–90

C E NT R AL IL L U STR AT IO N Multimodality Imaging for the Assessment of Tricuspid Regurgitation

Multi-modality Imaging for Assessment of Tricuspid

Relative Utility of Each Imaging Modality
Regurgitation Severity
Echocardiography Cardiac Computed
Parameters (TTE or TEE) Magnetic Tomography
2D/Doppler 3D/Color Resonance Angiography

Structural Parameters
Echocardiography
TV Morphology +++ +++ ++ ++
Tricuspid Valve Morphology
Regurgitant Cardiac Magnetic RV and RA size ++ +++ +++ +++
Pulsed and Continuous Volume Resonance +++ (proximal
Wave Doppler Criteria SVC and IVC Size +++ +++ +++
cavae only)
Color Doppler Criteria Right Heart Comprehensive
dimensions - - +++ +++
(2D and 3D) vascular assessment
Vena caval size Right Heart
Effective Regurgitant Semi-Quantitative parameters
Volumes and Function
Orifice Area TV Annular Jet Area +++ +++ ++ -
Dimensions Complete Vascular
Assessment Vena Contracta Width +++ +++ ++ -
Vena Contracta Area - +++ ++ -
Computed Tomography Anatomic Orifice Area - + ++ +++
Anatomic Regurgitant Orifice Area
Quantitative Parameters
Effective Regurgitant ++ (PISA and -
- -
Orifice Area Doppler SV) (see VCA)
++ (PISA and ++
Regurgitant Volume ++ -
Doppler SV) (from VCA)

Hahn, R.T. et al. J Am Coll Cardiol Img. 2019;12(3):469–90.

Although echocardiography remains the diagnostic modality of choice for the initial evaluation of the right heart and tricuspid valve, the Venn diagram illustrates the
utility and complementary nature of the imaging modalities for certain parameters important in the assessment of tricuspid regurgitation severity. The table shows the
relative strengths of each modality for the evaluation of specific parameters. IVC ¼ inferior vena cava; PISA ¼ proximal isovelocity surface area; RA ¼ right atrium; RV ¼
right ventricle; SV ¼ stroke volume; SVC ¼ superior vena cava; TEE ¼ transesophageal echocardiography; TTE ¼ transthoracic echocardiography; TV ¼ tricuspid valve;
VCA ¼ vena contracta area.

VENA CONTRACTA. A semiquantitative way to prognostic significance of a VC width of $7 mm in their

assess TR simply requires measuring the width of the
color jet at its narrowest point as it passes through the
VC. The 2017 American Society of Echocardiography
valve regurgitation guideline (1) suggests that a VC
width <3 mm indicates mild TR, whereas a VC width
$7 mm indicates severe TR. The noncircular and
nonplanar shape of the regurgitant TR orifice leads to
highly variable VC measurements depending on the
imaging plane. Finally, VC widths are influenced by
poor lateral resolution, flow rate, and machine set-
tings. In vitro studies have shown that VC width by
color Doppler can be more than double the size of
directly visualized orifices (15).
Three-dimensional (3D) color Doppler studies have
shown that the VC cross-sectional shape is often
ellipsoidal or crescent shaped with a long ante-
roposterior direction (Figure 4) (16). The septal-lateral
VC width was 0.39  0.37 cm smaller than the ante-
roposterior VC width (p < 0.001). VC widths and area
were strongly correlated with EROA. A recent early
feasibility trial of a new transcatheter TR repair device
confirmed that the mean minimum VC was 40% to 60%
smaller than the mean maximum VC (17). Despite
these limitations, Yang et al. (18) showed the
study of 74 patients with severe isolated TR assessed
by absolute jet area plus qualitative parameters. A VC
width of $7 mm from a single 4-chamber view was an
independent predictor of cardiovascular events on
multivariate Cox regression analysis (hazard ratio:
1.72; 95% confidence interval [CI]: 1.15 to 2.57; p <
0.01). A summary of color Doppler measurements of
regurgitation severity is listed in Figure 5.
CONTINUOUS WAVE VELOCITY PROFILE. The shape
and density of the continuous wave (CW) spectral
tracing of the TR jet contains useful, although quali-
tative, information about regurgitant severity. When
the tracing is weak and incomplete, TR is likely trivial
or mild, with denser spectra reflecting greater regur-
gitant volume. Most TR tracings are parabolic in
shape, reflecting the typical rise and fall of RV pres-
sure. When TR is severe, however, RA pressure rises
early in systole, resulting in an earlier systolic
maximal instantaneous transtricuspid gradient and
leads to a dense and triangular CW spectral shape
with early peaking of the velocity. Of note, in the
setting of severe, wide open TR, the peak jet velocity
is frequently low (<2.5 m/s).
JACC: CARDIOVASCULAR IMAGING, VOL. 12, NO. 3, 2019 Hahn et al. 473
MARCH 2019:469–90 TR Assessment

F I G U R E 1 Color Jet Area

A
TR Jet area = 8 cm2 TR VTI = 55 cm

TR Vel = 238 cm/s

B MR VTI = 147 cm
MR Jet area = 30 cm2

MR Vel = 539 cm/s

Jet flow is governed mainly by conservation of momentum (M), which is defined as flow (Q) multiplied by velocity (v) or effective regurgitant
orifice area (EROA)
v2. Thus, for the same EROA, the jet area (red dotted outline) for a TR jet (A) may be one-fourth the area of a mitral
regurgitant jet (B). In these examples, the EROA for both regurgitant jets is w55 to 60 mm2. The MR jet area is much larger than the TR jet
area but may be restricted by the eccentric, wall jet. CW ¼ continuous wave; EROA ¼ effective regurgitant orifice area; MR ¼ mitral
regurgitation; PG ¼ pressure gradient; TR ¼ tricuspid regurgitation; Vel ¼ velocity; VTI ¼ velocity time integral.

SYSTOLIC FLOW REVERSAL IN THE HEPATIC VEIN.
Analogous to pulmonary flow reversal in mitral
regurgitation, severe TR is often associated with
systolic flow reversal in the hepatic veins detected by
pulsed wave (PW) spectral Doppler from a subcostal
view (19). There is no specific regurgitant volume that
leads to flow reversal, as this is modulated by the size
and compliance of the RA, as well as by right ven-
tricular function. When the RA is small or systemic
venous pressure is high (and thus likely operating on
a steep pressure-volume curve), a smaller amount of
TR will raise inferior vena caval pressure enough to
reverse flow. When right ventricular function and
thus annular descent is reduced, a smaller amount of
474 Hahn et al. JACC: CARDIOVASCULAR IMAGING, VOL. 12, NO. 3, 2019

TR Assessment MARCH 2019:469–90

F I G U R E 2 Color Doppler Scale and Jet Area

A B C
Nyquist Limit= Nyquist Limit= Nyquist Limit=
63.9 cm/s 50.1 cm/s 30.8 cm/s

The color scale sets the upper limit that color Doppler can display without aliasing and the minimum velocity encoded. A to C show successively lower color scale and
progressively larger color jet areas in the same patient.

TR may also cause reversal of systolic flow. One
should be aware of potential causes of systolic he-
patic vein reversal unrelated to TR, such as ventric-
ular or junctional rhythm with retrograde P-waves.
A summary of PW and CW Doppler measurements
for assessing TR severity is listed in Figure 6.
PROXIMAL CONVERGENCE ANALYSIS. Although regur-
gitant jets are turbulent and exhibit aliasing, the
proximal convergence zone (on the right ventricular
side for TR) is laminar with smoothly accelerating
flow as the regurgitant orifice is approached. This
allows a relatively simple approach to quantitation,
applicable to both transthoracic and transesophageal
echocardiography (Figure 5). The theoretical un-
derpinnings of flow convergence analysis, or the
proximal isovelocity surface area (PISA) method,
assumes inviscid flow approaching a point orifice in
an infinitely broad, flat plane. In this admittedly

F I G U R E 3 Constrained Regurgitant Jet

A B

In these parasternal inflow views, A shows an eccentric jet directed toward the posterior wall, which is reduced in size due to chamber
constraint. With a similar regurgitant orifice, the central jet in B is larger.
JACC: CARDIOVASCULAR IMAGING, VOL. 12, NO. 3, 2019
MARCH 2019:469–90
F I G U R E 4 Shape of the TR Jet
A B
Because the shape of the TR jet is frequently irregular, the vena contracta (VC) diameters vary based on the imaging window. (A) Simultaneous multiplane imaging
shows different VC diameters. The 3D color Doppler image (B) aligns the green and red planes to image the VC in the blue plane. (C) The blue plane with S, P, and A
leaflets with the regurgitant jet between both the A-S and A-P commissures. A ¼ anterior leaflets; P ¼ posterior leaflets; S ¼ septal leaflets; other abbreviations in
Figure 1.
idealized setting, blood would approach the orifice
as a series of hemispheric isovelocity shells of
increasing velocity and decreasing surface area. For
a contour with velocity, v a, at radius, r, from the
orifice, the flow rate Q is given by [Q ¼ 2 pr 2v a]. The
contour is typically identified by shifting the aliasing
velocity (va ) until the red-blue (or yellow-cyan)
contour is easily measured and appears roughly
hemispherical. Once Q is known, then using the
conservation of mass principle (using the continuity
equation), the EROA is given by Q/V max, where Vmax
is the maximal velocity obtained from CW Doppler
through the jet at the time of the PISA radius mea-
surement. Multiplying this orifice area by the time-
velocity interval of the CW Doppler tracing should
then yield the regurgitant volume.
There are, of course, many places where errors can
arise in this analysis. First, regurgitant orifices are not
tiny points but a finite opening in the valve, and
contours flatten as they get closer to the orifice,
leading to underestimation of flow and orifice area by
approximately v a/Vmax . For mitral regurgitation, this
generally is negligible: using a 40 cm/s contour with a
5 m/s mitral regurgitation jet leads to approximately
8% underestimation in flow. With the much lower
Vmax of severe TR (2 to 3 m/s), this underestimation is
much more significant and may need correction (20).
Second, the regurgitant orifice in functional TR is
ellipsoidal with the largest orifice in the ante-
roposterior direction (16). Thus, the PISA generated
by this orifice would likely be hemielliptical and not
hemispheric. Finally, similar to mitral regurgitation
Hahn et al. 475
TR Assessment
C
P S
A1
(21), functional TR may vary over time, so a single
PISA radius measurement may not accurately quan-
tify the regurgitant orifice over the systolic time
interval.
Studies comparing the PISA method to angio-
graphic TR for gauging severity have suggested that
up to 20% to 30% of patients will have their TR
severity underestimated with this method (22).
Indeed, compared to quantitative EROA, PISA EROA
was consistently 40% to 50% smaller (17). This may be
related to the fact that the tethered tricuspid leaflets
will result in a proximal jet extent that is greater than
a hemisphere, which would result in a smaller PISA
radius. Correcting for the angle of the leaflets, Rivera
et al. (20) showed a high correlation between the
calculated TR volume and the quantitative Doppler
method (20). More recently, 3D PISA has been used to
quantify TR EROA (23) and correlated well with 3D-
planimetered VC area (VCA) (r ¼ 0.97). Further vali-
dation of this software is needed.
Despite these limitations, using the PISA method to
quantify regurgitation, Topilsky et al. (24) showed that
an EROA $40 mm 2 improved the prediction of out-
comes compared to qualitative measurements. The 10-
year survival rate and freedom from cardiac events
were lower with an EROA $40 mm 2 versus <40 mm 2,
independent of right ventricular size or function, co-
morbidity, or pulmonary pressure and lower than that
expected in the general population.
A summary of the American Society of Echocardi-
ography guidelines for assessing the severity of TR
are listed in Figure 7.
476 Hahn et al. JACC: CARDIOVASCULAR IMAGING, VOL. 12, NO. 3, 2019

TR Assessment MARCH 2019:469–90

F I G U R E 5 Summary of Color Flow Doppler Measurements

Color Flow Doppler 2D and 3D

Proximal flow convergence Apical 4 C View Advantages:
1. Align direction of flow with insonation beam 1. Align beam • Rapid qualitative assessment
2. Zoom 4. Nyquist
2. Zoomed view and variance off shift
Disadvantages:
3. Variance off
3. Change baseline of Nyquist limit in the direction of the • Underestimates severity with multiple jets
jet (yellow arrow) and adjust to obtain hemispheric flow 5. Radius (to • Non-hemispheric shape, particularly in the
vena contracta)
convergence (typically ~28 cm/s) setting of functional TR
4. Measure the radius from the point of color aliasing to • Overestimation when TR not holosystolic
the vena contracta (white arrow)
5. Consider angle correction

Vena contracta Advantages:

1. Optimize frame rates and line density by narrowing A VC = 1.8 cm B VC = 1.0 cm • Surrogate for regurgitant orifice size
sector or using zoom function particularly when average vena contract used
2. Panel A = Inflow View • Independent of flow rate and driving pressure
3. Panel B = Apical 4-chamber view for a fixed orifice
• Less dependent on technical factors
• Good at identifying severe TR (≥0.7 cm)
Disadvantages:
• Underestimates severity with multiple jets
• Imaging of convergence zone for measurement
• Overestimation when TR not holosystolic
Jet Area: Advantage:
1. Use the image with the largest jet area • Easy to measure
2. Maintain Nyquist limit at 50-70 cm/s Disadvantages:
• Dependent on the driving pressure and jet
direction
• Direction and shape of jet may overestimate
(central entrainment) or underestimate
(eccentric, wall-impinging) jet area
• Overestimation when TR not holosystolic
3D vena contracta Advantage:
1. Optimize 3-dimensional color Doppler frame rates and • Multiple jets of differing directions may be
line density by narrowing sector or using zoom function measured
2. Align orthogonal cropping planes using multi-planar Disadvantages:
reconstruction, along the axis of the jet with the short axis 1. Use narrow color flow sector
• Dynamic jets may be over- or underestimated
2. Align orthogonal cropping planes
image (red arrows) cutting the plane of vena contracta • Time consuming
3. Choose a point in the cycle corresponding to peak CW 3. Planimeter
• Limited spatial resolution will lead to
vena contracta
velocity and planimeter the vena contracta area area overestimation
Note: Non-coaxial jets or aliased flow may appear
“laminar” but still represent regurgitant flow

Summary of the color Flow Doppler measures of tricuspid regurgitation severity are listed. Reprinted with permission from Zoghbi et al. (1). VC ¼ vena contracta.

VOLUMETRIC QUANTIFICATION. In many ways, the
optimal approach to any regurgitant lesion is volu-
metric quantitation, comparing stroke volumes (SV)
through the regurgitant valve (i.e., the diastolic
stroke volume across the tricuspid valve) with a
reference SV from a region of the heart without
regurgitation or shunting (i.e., the left ventricular
outflow tract). This method can be used in the pres-
ence of dynamic or multiple jets and irregular orifices.
Few studies have used quantitation of TR by relative
SV (25). In those studies, a single plane tricuspid
annular diameter was measured from the 4-chamber
view, and the PW Doppler sample volume for
measuring the velocity-time-integral was placed at
the tips of the leaflets.
A refinement of the method uses orthogonal
plane annular diameters in early diastole (1 frame
after initial valve opening) in the formula for an
ellipse, may be a more accurate measurement of
annular area (Figure 7) (17). The orthogonal planes
used for measuring the tricuspid valve annulus
were the inflow view and the 4-chamber view or
measurements from a simultaneous biplane image
of the annulus. These authors obtained the
tricuspid annular velocity time integral from the
view with flow most parallel to the insonation beam
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F I G U R E 6 Summary of Pulsed and Continuous Wave Doppler Measurements

Pulsed Wave Doppler

Hepatic vein flow reversal Advantages:

• Align insonation beam • Simple supportive sign of severe TR
with flow in hepatic vein • Can be obtained with both TTE and TEE
Disadvantages:
• Depends on compliance of the right atrium
• May not be reliable in patients with atrial
fibrillation, paced rhythm with retrograde atrial
Severe TR conduction

Continuous Wave Doppler

Mild TR
Density of regurgitant jet Advantages:
• Align insonation beam • Simple
with direction of flow • Density is proportional to the number of red-
blood cells reflecting the signal
• Faint or incomplete jet is compatible with mild TR
Disadvantages:
• Qualitative
• Perfectly central jets may appear denser than
eccentric jets of higher severity
• Overlap between moderate and severe TR
Severe TR

Jet Contour Advantages:

• Align insonation beam • Simple
with direction of flow • Specific sign of pressure equalization in low
velocity, early peaking dense TR jet
Disadvantages:
• Qualitative
• Affected by changes that modify RV and RA
Severe TR pressures

A summary of pulsed and continuous wave Doppler measures of tricuspid regurgitation severity are listed. Reprinted with permission from
Zoghbi et al. (1). RA ¼ right atrium; RV ¼ right ventricle; TEE ¼ transesophageal echocardiography; TTE ¼ transthoracic echocardiography;
other abbreviations as in Figure 1.

(typically the apical view) with a PW sample volume
in the center of the annular orifice, at the level of
the annular plane in diastole. This
generally assumes a flat velocity profile (plug flow)
across what is often a severely enlarged tricuspid
annulus. However, given the annular shape and size
in patients with significant TR and the complex flow
patterns from the 2 venae cavae, annular flow is not
likely to be uniform, and this calculation may
grossly overestimate stroke volume and thus the
regurgitant volume itself.
Finally, for TR quantitation, the reference stroke
volume may be chosen from the right or left ventric-
ular outflow track, or the mitral inflow, or from left
ventricular volumetric stroke volume (preferably
with 3D volume assessment), all of which have been
documented to have reasonable accuracy (although
realistically no better than a standard error of
approximately 10%). These methods have recently
been summarized and are listed in Figure 8 (26).
approach 3D ECHOCARDIOGRAPHY. Although there has been
great progress in 3D echocardiography, there are still
challenges in volumetric quantitation of the right
heart, with significant underestimation of right ven-
tricular volumes (27), exacerbated in the setting of
massively dilated right ventricle, thus limiting its
utility for calculation and confirmation of total stroke
volume. A number of studies have shown the use-
fulness of 3D color Doppler to quantify TR (23,28–30).
The study by Velayudhan et al. (11) was one of the
first to correlate standard Doppler methods of quan-
tifying TR with planimetry of the 3D VCA. Using a
regurgitant jet area/right atrial area of >34% (11) and
the regurgitant jet area >10 cm 2 to define severe TR
(31), a 3D VCA by transesophageal echocardiography
of >0.75 cm 2 was the most sensitive cutoff value
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F I G U R E 7 Summary of American Society of Echocardiography Recommendations for Grading Severity of TR

Grading the Severity of Chronic TR by Echocardiography

TR Severity Mild Moderate Severe

Structural Bolded signs are considered specific for their TR grade.

Severe valve lesions (e.g., flail leaflet,

TV morphology Normal or mildly abnormal leaflets Moderately abnormal leaflets
severe retraction, large perforation)

RV and RA size Usually normal Normal or mild dilation Usually dilated1

Inferior vena cava diameter Normal <2 cm Normal or mildly dilated 2.1-2.5 cm Dilated >2.5 cm

Qualitative Doppler Bolded signs are considered specific for their TR grade.

Large central jet or eccentric wall-

Color flow jet area2 Small, narrow, central Moderate central
impinging jet of variable size

Flow convergence zone Not visible, transient or small Intermediate in size and duration Large throughout systole

CWD jet Faint/partial/parabolic Dense, parabolic, or triangular Dense, often triangular

Semiquantitative Bolded signs are considered specific for their TR grade.

2 2
Color flow jet area (cm ) Not defined Not defined >10
2
VCW (cm) <0.3 0.3-0.69 ≥0.7
3
PISA radius (cm) ≤0.5 0.6-0.9 >0.9
4
Hepatic vein flow Systolic dominance Systolic blunting Systolic flow reversal
4
Tricuspid inflow A-wave dominant Variable E-wave >1.0 m/s

Quantitative

EROA (cm2) <0.20 0.20-0.395 ≥0.40

5
RVol (ml/beat) <30 30-44 ≥45
1
RV and RA size can be within the “normal” range in patients with acute severe TR.
2
With Nyquist limit >50-70 cm/s.
3
With baseline Nyquist limit shift of 28 cm/s.
4
Signs are nonspecific and are influenced by many other factors (RV diastolic function, atrial fibrillation, RA pressure).
5
There are little data to support further separation of these values.

Reprinted with permission from Zoghbi et al. (1). CWD ¼ continuous wave Doppler; RVol ¼ regurgitant volume; VCW ¼ vena contracta width; other abbreviations as in
Figure 1.

(sensitivity: 85.2%; specificity: 82.1%). Chen et al.
(30), however, found that a 3D VCA of 0.36 cm 2 was
the best cutoff value for severe TR, with sensitivity of
89% and a specificity of 84% in predicting severe TR
defined by 2D echocardiographic integrative criteria.
This variability is likely due to the different criteria
used to define severe TR, and the lack of a true
comparator “gold standard” is the current limitation
to this technique.
A summary of the recommended (PISA) and pro-
posed methods of quantifying TR by echocardiogra-
phy are summarized in Figure 8.
PROPOSED GRADING SCHEME. Because of the late
presentation and the progressive nature of the disease,
it has been suggested that there should be grades of TR
beyond severe (32). In one study, a VC width of >11 mm
was consistent with “very severe” TR (33). A new
grading scheme has recently been proposed to help
determine efficacy of new transcatheter devices for
these patients, extending the severity scale for TR to
“massive” and “torrential” (Figure 9) (34). This scheme
is based on the ranges of values for lower grades of
severity and, importantly, has not been validated.
OTHER ECHOCARDIOGRAPHIC MEASUREMENTS OF
TR SEVERITY. Because of the numerous limitations of
color Doppler and the load-dependence of multiple
parameters, significant tricuspid annular dilation
measured by transthoracic echocardiography may be
a better predictor of severe late TR after mitral valve
surgery (35,36). Because of the relationship between
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F I G U R E 8 Summary of Proposed Quantitative Measurements of TR Severity

Measurements
Quantitation Method Example Calculation
Required
PISA 1. PISA radius [r] PISA Radius TR CW for Q = 2πr2va
2. PISA aliasing velocity [va] VTI
(approximately 28 cm/s) ROA = Q/Vmax
3. TR peak velocity [Vmax]
4. TR velocity time integral RegVol = ROA x TRVTI
[TRVTI]

Quantitative Doppler 1. LVOT Stroke Volume LVOT Diam LVOT VTI = Forward Stroke Volume:
• LVOT diameter -LVOTannulus Area x LVOTVTI
• LVOT PW

b Simultaneous
Biplane Imaging
2. Diastolic TVannulus Area Diastolic Stroke Volume =
a. Option 1: Inflow and TVannulus Area x TVVTI
a Inflow View 4ch View
4Ch TV annular
diameters
RegVol =
b. Option 2: simultaneous
C 3d Planimetry multiplane imaging Diastolic Stroke Volume –
aligned with the central Forward Stroke Volume
orifice
c. Option 3: Direct ROA = RegVol ÷ TRVTI
Planimetry of the 3D
Annular Area
annular area (green
circle) PW at Annulus
Note: Forward stroke volume
3. TV velocity time integral may be either the left
[TVVTI] ventricular or right ventricular
• PW Doppler sample stroke volume
volume at the annulus

3D Color Doppler 1. 3D color Doppler A B ROA ≈ VCA

volume planimetry of
the vena contracta area P S RegVol = VCA x TRVTI
(VCA) A1

2. TR velocity time integral 3D Multiplanar A

Reconstruction
[TRVTI] 3D Vena Contracta
Area

A summary of the recommended quantitative assessment of tricuspid regurgitation by PISA and other proposed methods of quantitation. 4Ch ¼ four-chamber; LVOT ¼
left ventricular outflow tract; PISA ¼ proximal isovelocity surface area; PW ¼ pulsed wave; Q ¼ flow; RegVol ¼ regurgitant volume; ROA ¼ regurgitant orifice area; TR
¼ tricuspid regurgitation; TV ¼ tricuspid valve; VTI ¼ velocity time integral. Reprinted with permission from Hahn et al. (26).

annular diameter and TR volume, an annular diam-
eter criterion has been used as a surrogate for regur-
gitation volume. Significant tricuspid annular dilation
is defined by transthoracic echocardiography as a
2
diastolic diameter $40 mm or >21 mm/m (37) in the
4-chamber apical view (36) and is an additional im-
aging criterion used to indicate severe TR in the
current the American Heart Association/American
College of Cardiology guidelines (37). Severe TR
(stages C and D) is associated with poor prognosis
independent of age, left ventricular and right ven-
tricular function, and right ventricular size (38,39).
With the use of more sophisticated imaging tech-
niques such as 3D echocardiography, Dreyfus et al.
(40) suggested that the cutoff value for severe TR
should be >42 mm or 23 mm/m 2, with other studies
suggesting annular dimensions may be related to
both sex and body size (41).
In addition to annular dimensions, other echocar-
diographic predictors of post-operative recurrent TR
include transthoracic echocardiographic measure-
ments of tricuspid valve tethering distance >0.76 cm
(42) or tethering area >1.63 cm 2 (43). Right ventricular
end-systolic area $20.0 cm 2 predicted worse
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F I G U R E 9 Proposed New Grading Scheme

Parameters MILD MODERATE SEVERE MASSIVE TORRENTIAL

Vena Contracta width

<3 mm 3-6.9 mm 7 mm - 13 mm 14-20 mm ≥21 mm
(biplane average)

EROA by PISA <20 mm2 20-39 mm2 40-59 mm2 60-79 mm2 ≥80 mm2

3D Vena Contracta
Area or Quantitative - - 75-94 mm2 95-114 mm2 ≥115 mm2
Doppler EROA

Example:

Given the late presentation of patients with functional TR, a new grading scheme has recently been proposed which extends the severity scale
for TR to “massive” and “torrential.” Because of the crescent shape of the TR orifice, the vena contracta width is the average of 2 orthogonal
views. The PISA method calculation of EROA may be smaller than the EROA by either 3D planimetry of the vena contracta area or by
quantitative Doppler calculations. Note that in the last example, there is low velocity laminar flow in the setting of rapid equilibration of
flow. Reprinted with permission from Hahn et al. (34). Abbreviations as in Figure 1.

F I G U R E 1 0 Cardiac Magnetic Resonance Prescription Planes Used for Evaluation of the Right Ventricle and Tricuspid Valve

4-Chamber

RVOT

2-Chamber

3-Chamber

Note that at each of the views, one of the tricuspid leaflets is always visualized but the other may vary based on slice positioning. Ant ¼
anterior leaflet; Post ¼ posterior; RVOT ¼ right ventricular outflow tract; Sep ¼ septal leaflet.
JACC: CARDIOVASCULAR IMAGING, VOL. 12, NO. 3, 2019 Hahn et al. 481
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F I G U R E 1 1 Indirect Calculation of TR volume and TR Fraction

End Diastolic End Systolic

A B C

D E F H
Reg. Volume =
101-46 =
55 ml/beat
G
Reg. Fraction =
55/101 = 54%

(A) The initial scout long-axis reference image used to identify the correct short-axis slice used for volumetric analysis. Note that a few extra slices are obtained to
ensure coverage of the entire right ventricle from the base to the apex. (B) The diastolic short-axis stack from base to apex, starting immediately on the myocardial side
of the atrioventricular junction at end-diastole. RV endocardial borders are traced (yellow line). (C) The systolic short-axis stack from base to apex with fewer traced
images because of the descent of the cardiac base. (D) The volumetric assessment of stroke volume using the quantification derived from B and C. (E) The level at
which through-plane phase contrast imaging of pulmonic flow (F) is taken, immediately above the pulmonic valve. Total forward flow is than measured (G). (H) The
calculation of TR volume as the difference between the total RV stroke volume (D) and forward stroke volume (G).

event-free survival in patients undergoing isolated CARDIAC MAGNETIC RESONANCE

tricuspid valve surgery (44). Measurements of right QUANTIFICATION OF
ventricular systolic function remain unclear de- TRICUSPID REGURGITATION
terminants of outcome, with some studies suggesting
no significant impact (44,45). Dreyfus et al. (36) CMR assessment of TR is feasible, but less established
studied intraoperative predictors of worsening TR than that of other regurgitant valvular lesions. Eval-
and found that 48% of patients with a tricuspid uation of associated right-sided chamber remodeling
annular dimension of >70 mm (septolateral dimen- and function is an important feature of CMR, which
sion) had worsening TR over time if not repaired at does not require use of contrast. Although indirect
the time of surgery (compared to only 2% with a and direct quantitative methods have been studied,
concomitant repair). Recent studies, however, have categorization of TR severity by CMR has not been
called into question the appropriateness of this open validated due to lack of adequate reference
surgical, stretched annulus measurement (40). Right standards.
atrial volume in some studies has also been associ- QUALITATIVE ASSESSMENT. One of the major ad-
ated with severity of TR (13,14,46). Utsunomiya et al. vantages of CMR is the capability of visualizing the
(14) showed that, in patients with atrial fibrillation, right-sided chamber size and function without
only the tricuspid valve (TV) annular area in mid- ionizing radiation and/or use of intravenous contrast.
systole (coefficient: 0.059; 95% CI: 0.041 to 0.078 The TV and tricuspid valve anatomy can be seen in
per 100 mm 2; p < 0.001) was associated with TR multiple planes which requires appropriate planning
severity. In addition, annular area was more closely and correct slice prescriptions (Figure 10). Although
correlated with the right atrial volume than right short-axis cine images are the basic views for the right
ventricular end-systolic volume (p < 0.001). ventricle, if TR is suspected, contiguous cine slices of
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TR Assessment MARCH 2019:469–90

F I G U R E 1 2 Cardiac Magnetic Resonance 4D Flow Imaging Assessment of TR

A B

A multiplanar reconstruction still frame from a 4D CMR velocity-encoded acquisition is shown with retrospective valve tracking (see Video 1).
In this systolic frame, high-velocity TR flow is represented by a bright green color. The crosshairs can be manipulated in the long-axis images
(A and C) to align flow, which can then be measured in the short-axis through-plane of the TR jet (B). Valve tracking (B, polygon) allows
semiautomated adjustment of through-plane motion for more accurate assessment of flow. CMR ¼ cardiac magnetic resonance; other
abbreviation as in Figure 1. Figure was supplied courtesy of Melany Atkins, MD.

5 to 6 mm, without interval gaps, are required
covering the entirety of the tricuspid valve.
Qualitative assessment of TR by CMR imaging is
performed by visualizing the area of local signal drop
(spin dephasing) which occurs due to flow turbulence
and/or acceleration. Although the visual/qualitative
grading has been shown to have moderate correlation
with quantitative assessment (47), there are impor-
tant caveats to consider with this semiquantitative
approach. First, the current most commonly used
steady-state free precession cine imaging demon-
strates a less pronounced flow void than the gradient
echo sequences used in the past. Second, the
appearance of the regurgitant jet is affected by plane,
slice thickness, windowing, flip angle, and echo time
(48). Thus, differentiating mild from severe disease is
usually possible by using qualitative assessment;
however, finer degrees of differentiation are often
challenging. Third, CMR conditional pacemaker leads
can produce susceptibility artifacts which can make
TR jet visualization difficult. In addition, a pacemaker
generator can create magnetic field inhomogeneity
which can affect quality of phase-contrast (PC)
imaging, although this artifact can be reduced if the
vessel of interest is kept at the magnet isocenter.
Fourth, appearance of flow voids/spin dephasing may
be more pronounced with higher magnetic fields
(i.e., 3.0-T vs. 1.5-T), making interpretation more
variable and difficult.
QUANTITATIVE ASSESSMENT. CMR has usually been
considered the gold standard technique for quanti-
tative valvular assessment. However, CMR-specific
cutoff values for TR severity as a function of regur-
gitant volume and regurgitant fraction are currently
unknown. The latest guidelines suggest adopting the
same regurgitant fraction severity thresholds for TR,
that have been used for mitral regurgitation (i.e., a
regurgitant fraction of #15% for mild TR; 16% to 25%
for moderate TR; 26% to 48% for moderately severe;
and >48% for severe TR. (1,49). This requires further
study.
INDIRECT CALCULATION OF REGURGITANT
VOLUME. CMR is considered the gold standard for
right ventricular volumetric quantification due to the
complex shape of the right ventricle as well as
excellent endocardial definition, independent of
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F I G U R E 1 3 Different Pulse Sequences Used for CMR Cine Imaging in a Patient With Atrial Fibrillation and Congestive Heart Failure

Free Breathing Real-Time with

Averaging of Multiple Beats and
Breath-Held Segmented Free Breathing Real-Time Gadgetron Image Reconstruction

Routine cine imaging using breath-held segmented steady-state free precession has lots of blurring both from cardiac arrhythmia and breathing motion (left panel)
(see Video 2). Free-breathing real-time cine (middle panel) is feasible by acquiring the image quickly at the expense of lower temporal and spatial resolution.
Free-breathing real-time cine (right panel) acquiring multiple heart beats is using compressed sensing, and Gadgetron image reconstruction allows construction of an
average cine image with excellent spatial and temporal resolution, which allows for volumetric quantification.

body habitus (50). Volumetric analysis of the right
ventricle is performed without geometric assump-
tions by measurement and interpolation of a short-
axis stack of cine CMR images from the base to the
apex of the right ventricle. These analyses are typi-
cally acquired one at a time, as separate, electrocar-
diographic (ECG)-gated, breath-held acquisitions,
lined up based on initial long-axis scout images. It is
important to start immediately on the myocardial
side of the atrioventricular junction at end diastole; at
this slice, end-systolic images will contain likely only
atrial volume because of the descent of the cardiac
base and should be excluded from volumetric anal-
ysis. The endocardial border of each slice is traced at
end diastole and end systole from which right ven-
tricular volumes are calculated by adding the vol-
umes of the individual slices using
automation (Figures 11A to 11D), with particular
attention to avoid misalignment of the short-axis
images. In dilated or hypertrophied right ventricles,
the presence of trabeculations may affect volume and
mass measurements. Although there is still debate
about the appropriate methodology (51), unless there
are software tools that are capable of performing
semiautomated pixel-intensity papillary muscle and
trabeculation exclusion, the present authors’ recom-
mendation is to include those in the right or left
ventricular cavity volumes for better reproducibility.
After calculation of right ventricular volumetric
stroke volume (RVSV), the tricuspid regurgitant vol-
ume (RVol) is then derived as total RVSV minus a
reference systemic SV. There are 3 possible reference
SV which can be subtracted to obtain the RVol: 1) PC
imaging of the pulmonic valve (in the absence of pul-
monic regurgitation) (Figures 11E to 11G); 2) PC imaging
of the aortic valve (in the absence of aortic regurgita-
tion); and 3) volumetric left ventricular stroke volume
(in the absence of aortic or mitral regurgitation).
PC is also referred to as velocity-encoded imaging or
velocity mapping. A velocity-encoded short-axis slice
just above the level of the valve plane (pulmonic or
aortic) may be used to directly quantify flow across
the valve (forward SV). Care must be taken to align the
velocity-encoded slice perpendicular to the direction
of flow, otherwise forward SV could be under-
estimated. The region of interest must also be drawn
around the flow region, without including any
software external flows (Figures 11E and 11F). If possible, RVol
should be obtained from multiple methods to deter-
mine internal consistency and increase confidence
in the assessment of TR severity.
Using this method, Park et al. (52) recently showed
that, in patients with severe functional TR (mean TR
regurgitant fraction: 46  16%) who underwent iso-
lated TR surgery, volumetric quantification of right
ventricular end-systolic volume index and right
ventricular ejection fraction by CMR are important to
predict post-operative all-cause and cardiac mortal-
ity. Further studies are needed to evaluate whether
quantification of TR severity by CMR can yield in-
cremental risk stratification beyond volumetric
parameters.
484 Hahn et al.
TR Assessment
F I G U R E 1 4 Computed Tomography Indirect Imaging Findings of Severe TR
A B
SVC
RA
IVC
(A) Coronal projection showing intravenous contrast arriving from the SVC, passing through the RA and being directed toward the IVC due to
severe TR. (B) Axial imaging shows intravenous contrast arriving into the IVC and reaching the HV which is a specific finding for severe TR.
HV ¼ hepatic vein; IVC ¼ inferior vena cava; SVC ¼ superior vena cava; other abbreviation as in Figure 1.
DIRECT CALCULATION OF REGURGITANT VOLUME.
PC imaging can also be used to directly measure
regurgitant flow through valves. Flow assessment
using the PC technique has been validated in vivo and
by invasive in vivo flow measurements (53,54).
Semilunar valve regurgitation is a common and
straightforward use of PC imaging due to the stable
position of the aortic and pulmonic valves. Direct PC
assessment of the atrioventricular valves however is
challenging due to significant motion and the
nonplanar, saddle shape of the atrioventricular
annuli. Although there have been a few reports of
success with direct PC imaging of the atrioventricular
valves (55,56), this technique has not been widely
reported in published studies.
4D FLOW IMAGING. A very promising, novel
approach is 4D flow velocity-encoded imaging. This
has the potential to more accurately analyze the
complex, 3D nature of cardiac flow than current
methods. 4D flow imaging allows free breathing,
time-resolved whole-heart acquisition with velocity
encoding in all directions. A standard multiplanar
technique can then be used to align the measurement
plane perpendicularly to the flow direction off line
(Figure 12, Video 1). 4D flow has been used in a
research capacity for several years (57). However, ef-
forts have largely focused on the left heart so that
more validation of TR measurements are needed. In a
recent review (58), only 2 of 1,608 screened publica-
tions studied TR (59,60). Retrospective valve and
annulus tracking are features which have been
JACC: CARDIOVASCULAR IMAGING, VOL. 12, NO. 3, 2019
MARCH 2019:469–90
HV
IVC
studied previously and are available in newer 4D flow
analysis software. This may be a solution to the issue
of in-plane motion of the tricuspid annulus, which is
encountered during direct 2D PC TR quantitation.
A very recent publication showed excellent correla-
tion of 4D flow directly measured TR with conven-
tional CMR methods (61). Theoretically, 4D flow
measurements should be more accurate than 2D
methods, but further clinical and prognostic valida-
tion are needed. Volumetric analysis may also theo-
retically be performed from free-breathing 3D whole-
heart acquisition (62) or from 4D flow acquisition,
although further validation of these techniques is
needed. Although 4D flow dataset acquisition and
post-processing times have recently improved, this
technique remains investigational at this time.
LIMITATIONS AND DEVELOPMENTS OF CMR.
Patients with significant mitral and/or tricuspid
regurgitation tend to develop atrial dilation which
predisposes them to atrial arrhythmia. Arrhythmia
could be an important limitation for CMR quantifica-
tion of right ventricular volumes and TR feature of
CMR, which does not require use of contrast. There
are several ways to circumvent this problem. In case
of frequent premature atrial or ventricular contrac-
tions, arrhythmia rejection could be an option.
Although this tends to increase the breath-hold time
and cause some image blurring, interpretation is
feasible. For cases of atrial fibrillation, one possibility
is to use prospective ECG triggered acquisition, which
relies on partial signal and image acquisition
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F I G U R E 1 5 Computed Tomography Measurement of AROA

Multiplanar reconstruction planes are aligned at the tips of tricuspid valve leaflet at mid-peak systole (20% to 40% of the R-R interval). TR AROA is then traced using cubic
spline interpolation, yielding an area of 0.77 cm2, which is consistent with severe TR. AROA ¼ anatomical regurgitant orifice area; other abbreviations as in Figure 1.

triggered by the R-wave. One disadvantage is that in typically instructed to continue with shallow breaths
order to not miss the next cardiac cycle, the end- during image acquisition but to increase the number
diastolic period is typically missed (last 10% of R-R of signal averages to a minimum of 3. This acquisi-
interval), so volumes could be underestimated (63). tion will typically last for 45 to 60 s and will inte-
Another possibility is to use real-time cine imaging grate and average multiple heart beats. Post-
with free breathing which would produce images processing is the same as in breath-held acquisition
similar to echocardiography, albeit with lower tem- (66).
poral and spatial resolution, given the short interval
for signal acquisition. QUANTITATION OF TR USING
Technological developments with the use of com- COMPUTED TOMOGRAPHY ANGIOGRAPHY
pressed sensing, sparsity based methods, and Gadg-
etron image reconstruction (GitHub, San Francisco, Quantitation of TR has not been systematically
California) have now allowed generation of real-time investigated using CTA. However, due to the meth-
free-breathing cine images with excellent image odological limitations observed with echocardiogra-
quality with superior spatial and temporal resolution phy (particularly the underestimation of TR severity
as compared to the traditional breath-held segmented by the PISA method and interobserver variability of
acquisition (64,65) (Figure 13, Video 2). In the present the quantitative Doppler method), CTA can provide
authors’ personal experience, this sequence has been valuable information in patients with suboptimal
of great value to patients with atrial fibrillation transthoracic echocardiographic imaging quality
because it creates clear cine imaging averaging many where there is unclear TR grading and/or adequate
cardiac cycles, which allows for volumetric analysis visualization of the right ventricular remodeling and
and quantification. function. Furthermore, an integrative approach
In regard to PC imaging for patients with cardiac considering data from several imaging modalities is
arrhythmia, including atrial fibrillation, patients are likely to improve diagnostic accuracy.
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F I G U R E 1 6 Computed Tomography Measurement of the Tricuspid Annulus Using Multiplanar Reconstruction and Cubic Spline Interpolation

4ch Diameter
Tricuspid Annulus
Early Diastole

Area & Major/Minor Diameter

2ch Diameter

Multiplanar reconstruction planes are aligned at the tips of tricuspid valve leaflets at early diastole (60% to 70% of the R-R interval). The tricuspid annulus is measured
in the long-axis 2- and 4-chamber reformats. The derived 3D plane then allows for measurement of the tricuspid area, major, minor diameters, and perimeter by using
cubic spline interpolation. 2ch, 4ch ¼ 2-chamber, 4-chamber.

CTA IMAGING ACQUISITION FOR TRICUSPID REGURGITATION
EVALUATION. Electrocardiogram-gated
retrospective acquisition should cover the entirety of
the cardiac cycle. This is key to enable subsequent
multiplanar reconstruction at the correct part of the
cardiac cycle, using the most stationary phase. Newer
generation scanners with a higher number of de-
tectors have increased the z-axis coverage allowing
shorter breath-hold duration and lower radiation
dose and contrast volume. However, more important
than having greater z-axis coverage is to have
adequate temporal resolution at the time of image
acquisition. Atrial fibrillation, which is common in
these patients, poses a challenge to older generation
CTA scanners, in which a lower number of detector
rows and lower temporal resolution can cause
important motion/misregistration artifacts, causing
blurring, distortion, and inadequate visualization of
the cardiac structures. Adequate temporal resolution
(preferably <80 ms) can be achieved with dual-source
multiphasic scanners or, in single-source scanners, with multi-
segmented reconstruction algorithms at the expense
of longer scanning times (lower pitch), greater radia-
tion, and contrast use (67).
Furthermore, optimal contrast enhancement of the
right heart requires a dedicated CTA contrast protocol
(68). Intravenous injection of nonionic contrast agent
is typically performed by using a biphasic or prefer-
ably triphasic protocol (69) (e.g., a 60%/40% contrast/
saline mixture at a rate of 4 ml/s, followed by a 25%/
75% contrast/saline mixture at a rate of 4 ml/s, and
finally, 20 ml of normal saline at 4 ml/s). CTA pro-
tocols that account for the patient’s weight, left
ventricular ejection fraction, and heart rate have been
published (70). Generally, a final saline flush will
ensure that the contrast bolus remains compact. A
prolonged injection of pure contrast should be avoi-
ded as it may lead to streak and beam hardening
JACC: CARDIOVASCULAR IMAGING, VOL. 12, NO. 3, 2019
MARCH 2019:469–90
F I G U R E 1 7 Computed Tomography Semiautomated Measurement of the Tricuspid Annulus by Using Off-Label Mitral Valve Module (CVI42 version 5.6.4, Circle,
Calgary, Canada)
Analysis provides 3D display of the saddle-shaped dilated tricuspid annulus as well as the S curve to identify the fluoroscopic projection angle for best coplanar
alignment with the tricuspid annulus.
artifacts due to of contrast medium mixing with
nonenhanced blood. Early opacification of the infe-
rior vena cava or hepatic veins on first-pass contrast-
enhanced CTA indicates the presence of TR with high
sensitivity and specificity and allows for semi-
quantitative grading (71) (Figure 14).
Nondedicated CTA scan (e.g., performed
transcatheter aortic valve replacement evaluation)
with an opacification of the right heart cavities
of $200 Hounsfield units may also be suitable for
interpretation. Beam-hardening artifacts produced
by pacemakers and other implantable
defibrillator leads can impair image quality but
images are often interpretable. Significant cardiac
arrhythmias (i.e., atrial fibrillation with rapid ven-
tricular response and/or frequent premature ventric-
ular contractions) coupled with inadequate CTA
scanner temporal resolution can cause suboptimal
image quality. In our experience, only approximately
5% of the dedicated CTA studies performed for
Hahn et al. 487
TR Assessment
evaluation of transcatheter tricuspid valve repair are
not interpretable due to severe artifacts.
CTA QUANTIFICATION OF TR. Although direct
quantification of TR is not feasible with CTA, in the
absence of significant intracardiac shunting and/or
valvular regurgitation, the tricuspid regurgitant vol-
for
ume can be calculated as the difference between the
volumetric right ventricular SV and the left ventric-
ular SV, as described using CMR (1).
ANATOMICAL SURROGATES OF TR SEVERITY.
cardiac- Because variability and difficulty in quantification of
TR severity can occur using even the multiparametric
approach, identification of anatomical surrogates of
TR severity have been described. Using CTA, 2
different methods may be considered for TR severity
grading: measurement of the anatomic regurgitant
orifice area during systole (AROA) and quantification
of the tricuspid annular area in diastole.
488 Hahn et al. JACC: CARDIOVASCULAR IMAGING, VOL. 12, NO. 3, 2019

TR Assessment MARCH 2019:469–90

MEASUREMENT OF THE ANATOMIC REGURGITANT than 14 to 15 cm 2 is associated with severe functional

ORIFICE AREA. As recently described for the mitral
valve (72), measurement of the AROA by CTA is
feasible and may be used as an additional grading
tool of TR severity in patients with discrepant
echocardiographic measurements. For this purpose,
multiplanar reconstruction is performed with the
reformation planes aligned with the
portion of the regurgitant orifice during mid/peak
systole (20% of the R-R interval). The borders of the
AROA are delineated by the leaflet tips of the
tricuspid valve. The contours of the AROA are then
traced on the reconstructed short axis by depositing
points or nodes connected by cubic spline interpo-
lation. (Figure 15). The latter method accounts for
the curvilinear shape of the regurgitant orifice, a
feature that is more pronounced for the tricuspid
than the mitral valve. In the present authors’ expe-
rience, the measured area is generally larger than
the corresponding 3D Doppler VC area, which cor-
responds better to the functional regurgitant orifice
area.
MEASUREMENT OF THE TRICUSPID ANNULAR AREA.
With the emergence of percutaneous tricuspid treat-
ment techniques, measurement of the tricuspid
annular area is useful for percutaneous
replacement or annuloplasty sizing and also for
assessment of the results after intervention. Indeed,
more so than for MR, the severity of TR closely relates
to the size of the tricuspid annulus as annular dilation
represents the leading mechanism in secondary TR
(73,74). In addition, annular dimensions impact clin-
ical outcomes (75) and could be potentially be linked
with transcatheter procedural success. In the present
authors’ experience, a tricuspid annulus area of more
TR.
Several methods can be used for measurement of
the tricuspid annular area with CTA, including mul-
tiplanar reconstruction and cubic spline interpola-
tion. In keeping with echocardiography reports, the
measurement should be performed in mid-diastole
narrowest (60% to 80% of the R-R interval), or 1 frame after
the opening of the tricuspid valve. For multi-planar
reconstruction, the planes are manually aligned with
the valve annulus from the long-axis 2- and 4-
chamber views as previously described (76)
(Figure 16). Cubic spline interpolation can be obtained
through off-label use of the algorithms developed for
the mitral or through tricuspid specific modules
which allow semiautomated segmentation of the
tricuspid annulus and fluoroscopic angle of implant
(Figure 17).
CONCLUSIONS
The strengths and limitations of standard and novel
methods of assessing TR severity by echocardiogra-
phy, CMR, and CTA have been presented. Although
echocardiography remains the first-line imaging mo-
valve dality in the guidelines, greater use of advanced im-
aging technology and techniques such as CMR and
CTA may improve the ability to accurately and
reproducibly quantify this disease.
ADDRESS FOR CORRESPONDENCE: Dr. Rebecca T.
Hahn, Columbia University Medical Center, New
York-Presbyterian Hospital, 177 Fort Washington
Avenue, New York, New York 10032. E-mail: rth2@
columbia.edu.

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KEY WORDS cardiac magnetic resonance,
computed tomography angiography,
echocardiography
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