Tricuspid Valve Remodeling in a New Grading Scheme for Functional Tricuspid Regurgitation: A Three-Dimensional Echocardiography Study
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Background
The specific 3D morphological substrates distinguishing the newly defined “massive” and “torrential” functional tricuspid regurgitation (FTR) phenotypes from standard severe disease remain under-characterized.
Objectives
This study investigates the 3D geometric changes of the tricuspid valve (TV) apparatus across the spectrum of FTR, specifically focusing on the structural definition of massive and torrential grades.
Methods
Three-dimensional (3D) transesophageal echocardiography (TEE) was performed in 322 patients with FTR secondary to left-sided heart disease. Patients were stratified into mild-moderate (n=166), severe (n=82), and massive-torrential (n=74) groups. TV geometry, including annular dimensions, leaflet tethering, and subvalvular apparatus, was quantified using 3D modeling software.
Results
Patients with massive-torrential TR were characterized by advanced age, female predominance, and atrial fibrillation (75%). 3D analysis demonstrated that massive-torrential TR represents a distinct phenotype defined by extreme annular circularization (ellipticity index ≈ 1.0) and planar flattening ( P < 0.001). Furthermore, these patients exhibited a critical “leaflet-annulus uncoupling”, where compensatory leaflet growth (relative length < 80%) failed to match the massive annular dilation. Consequently, the regurgitant orifice in massive-torrential grades appeared highly complex, frequently manifesting as multiple irregular orifices.
Conclusions
Massive and torrential FTR are characterized by a unique geometric profile involving extreme annular circularization, severe leaflet tethering, and leaflet-annulus uncoupling. These morphological insights suggest that conventional repair strategies may be insufficient for these advanced phenotypes, highlighting the necessity for pre-procedural 3D TEE to guide device selection.
