The Last Decade in Tricuspid Regurgitation: How Imaging Shaped a Field (JIMG September 2025)-Article: The Last Decade in Tricuspid Regurgitation: How Imaging Shaped a Field

Article: The Last Decade in Tricuspid Regurgitation: How Imaging Shaped a Field

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This 2025 comprehensive review underscores the transformative role of advanced imaging in the diagnosis, characterization, and treatment of tricuspid regurgitation (TR), a condition increasingly recognized for its association with elevated mortality and reduced quality of life. Over the past decade, the “forgotten” tricuspid valve has garnered attention with multiple device approvals for structural interventions, particularly transcatheter therapies, reflecting progress from early surgical challenges to effective, less invasive interventions.<br /><br />Echocardiography remains the first-line modality for assessing TR etiology and severity, evolving from standard 2D to advanced 3D techniques enhancing visualization, quantification, and intervention guidance. Multimodality imaging—including cardiac computed tomography angiography (CTA) and cardiac magnetic resonance (CMR)—complements echocardiography by providing detailed anatomical, functional, and tissue characterization essential for procedural planning and prognostication.<br /><br />A novel classification system distinguishes TR etiologies into primary, atrial secondary, ventricular secondary, and cardiac implantable electronic device (CIED)-related TR, emphasizing the prognostic differences and guiding treatment selection. Quantification of TR severity has advanced beyond traditional mild-moderate-severe grading to a five-tier scheme (mild, moderate, severe, massive, torrential) incorporating novel parameters such as 3D vena contracta area and volumetric methods to improve risk stratification and guide timing of interventions.<br /><br />Right heart remodeling assessment—including right ventricular (RV) size, function, and right atrial (RA) enlargement—through parameters like TAPSE, RV free-wall longitudinal strain, effective RVEF, and RV-pulmonary artery coupling indices—provides critical prognostic insights and informs patient selection for repair versus replacement approaches.<br /><br />Imaging is integral across the care continuum: from screening and anatomical suitability assessment, through intraprocedural guidance using fusion imaging and multiplanar reconstruction, to postprocedural evaluation of residual TR, device performance, and right heart reverse remodeling.<br /><br />Emerging technologies such as artificial intelligence (AI) and computational modeling promise to enhance diagnostic accuracy, risk prediction, personalized therapy planning, and procedural efficiency.<br /><br />Overall, advanced multimodality imaging has not only reshaped understanding of TR pathophysiology and severity but also optimized patient selection, timing, and outcomes of novel transcatheter interventions, marking a paradigm shift in management of this once neglected valve disease.

Keywords

tricuspid regurgitation

advanced imaging

echocardiography

transcatheter therapies

multimodality imaging

right heart remodeling

3D vena contracta area

artificial intelligence in cardiology

cardiac computed tomography angiography

cardiac magnetic resonance