This narrative review proposes a six-domain, phenotype-based multimodality imaging framework to distinguish atrial and ventricular secondary tricuspid regurgitation and guide transcatheter intervention timing and planning.
May support multimodality phenotyping in secondary tricuspid regurgitation; leaves open prospective validation before guiding interventions.
Tricuspid regurgitation (TR) is a heterogeneous valvular disorder affecting an estimated 1.6 million adults in the United States, with increasing clinical relevance in the era of transcatheter intervention. Accurate etiologic classification is essential because primary, secondary, and cardiac implantable electronic device (CIED)-related TR arise through distinct mechanisms and carry different imaging, prognostic, and therapeutic implications. Contemporary multimodality imaging, including transthoracic echocardiography (TTE), three-dimensional echocardiography, transesophageal echocardiography (TEE), cardiac magnetic resonance (CMR), and cardiac computed tomography (CT), enables integrated assessment of valve anatomy, right-heart remodeling, pulmonary hemodynamics, and procedural suitability. In this narrative review, we propose a phenotype-based approach to secondary TR organized across six domains: chamber morphology, right atrial mechanics, annular geometry, leaflet morphology, right ventricular systolic function, and pulmonary hemodynamics. Integration of these domains may support assessment of atrial secondary TR (A-STR) and ventricular secondary TR (V-STR), while recognizing patients with overlapping atrial and ventricular features. Throughout, we distinguish consensus-derived phenotyping parameters from supportive prognostic associations and identify areas where evidence remains insufficient. We further discuss how multimodality imaging may inform procedural planning and intervention timing and highlight emerging echocardiographic markers, including right atrial reservoir strain, effective right ventricular ejection fraction (eRVEF), and CMR tissue characterization that warrant prospective validation for phenotyping, risk stratification, and assessment of myocardial reversibility. Together, this conceptual framework, which requires prospective validation, is intended to complement severity-based classification with a mechanism-informed approach to TR diagnosis and management.
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Sanchez et al. (2026) studied this question.
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