Table 1 Open in new tab Proposed...

Definition criteria for A-STR

Recommended cut-offs and caveats

1. Clinically relevant STR (greater or equal to moderate)

Alternative causes of STR and the typical imaging features of primary TR should be adequately ruled out^a

VC width (biplane) ≥ 3 mm
PISA radius ≥ 5.5 mm
PISA EROA ≥ 20 cm²
PISA regurgitant volume ≥ 30 mL
Regurgitant fraction ≥ 16%⁴⁹

2. Predominant TA dilation

Limits of normality for parameters of TA size depend on sex, body size, view, and timing of measurement during the cardiac cycle

2D Echo measurements at end-diastole^48,50:

Four-chamber TA diameter: >40 mm (22 mm/m²) for men and >35 mm (21 mm/m²) for women
RV-focused TA four-chamber diameter: >41 mm (24 mm/m²) for men and >38 mm (22 mm/m²) for women

3D echo measurements at end-diastole by automated TV-specific software⁵⁰:

Major (largest) TA diameter: >46 mm (27 mm/m²) for men and >43 mm (26 mm/m²) for women
TA area: >13.8 cm² (8.4 mm/m²) for men and >11.7 cm² (6.9 mm/m²) for women⁵⁰
TA perimeter: >13.7 cm (8 cm/m²) for men and >12.5 cm (7.8 cm/m²) for women

3. Predominant RA dilation with increased end-systolic RA:RV ratio

RA dilation is not specific for A-STR, but rather its disproportion compared with RV size

2D RA volume: >34 mL/m² for men and >29 mL/m² for women
3D RA volume: >38 mL/m² for men and >34 mL/m² for women⁵¹

End-systolic RA:RV volume (or area) ratio ≥ 1.5 is suggestive of A-STR^2,3,43

4. Absence of significant tricuspid leaflet tethering

Single-plane measurement of coaptation height might underestimate leaflet tenting in case of asymmetric tethering

Absence of significant TV leaflet tethering is defined by

tenting height ≤ 9 mm
tenting area < 2.1 cm²
tenting volume <2.5 mL^43,52
leaflet angle < 15°²

5. RV conical remodelling with predominant enlargement of RV basal dimension

RV sphericity is a surrogate index reflecting conical (triangular) RV remodelling, and is calculated as (RV midventricular diameter × RV longitudinal diameter)/RV basal diameter

RV sphericity index < 55⁴⁹
RV midventricular diameter is normal (≤ 38 mm or ≤ 21 mm/m²)
RV basal diameter is enlarged (≥ 45 mm or ≥ 24 mm/m² for men, ≥ 40 mm and ≥ 20 mm/m² for women)⁴⁸

6. Preserved LV and RV systolic function

Preserved bi-ventricular function criteria may not apply if the A-STR patient is evaluated during AF with relatively rapid ventricular response or in the late stages of severe to torrential A-STR (with/without significant A-SMR)

LVEF ≥ 50%
3D RVEF ≥ 50%
RVFWLS ≤ −20% (≤−23% for mid-wall strain)
RV TDI S’ ≥ 9 cm/s
FAC ≥ 35%
TAPSE > 17 mm^49,52

(in SR or rate-controlled AF and in earlier stages of the A-STR disease)

Definition criteria for A-STR

Recommended cut-offs and caveats

1. Clinically relevant STR (greater or equal to moderate)

Alternative causes of STR and the typical imaging features of primary TR should be adequately ruled out^a

VC width (biplane) ≥ 3 mm
PISA radius ≥ 5.5 mm
PISA EROA ≥ 20 cm²
PISA regurgitant volume ≥ 30 mL
Regurgitant fraction ≥ 16%⁴⁹

2. Predominant TA dilation

Limits of normality for parameters of TA size depend on sex, body size, view, and timing of measurement during the cardiac cycle

2D Echo measurements at end-diastole^48,50:

Four-chamber TA diameter: >40 mm (22 mm/m²) for men and >35 mm (21 mm/m²) for women
RV-focused TA four-chamber diameter: >41 mm (24 mm/m²) for men and >38 mm (22 mm/m²) for women

3D echo measurements at end-diastole by automated TV-specific software⁵⁰:

Major (largest) TA diameter: >46 mm (27 mm/m²) for men and >43 mm (26 mm/m²) for women
TA area: >13.8 cm² (8.4 mm/m²) for men and >11.7 cm² (6.9 mm/m²) for women⁵⁰
TA perimeter: >13.7 cm (8 cm/m²) for men and >12.5 cm (7.8 cm/m²) for women

3. Predominant RA dilation with increased end-systolic RA:RV ratio

RA dilation is not specific for A-STR, but rather its disproportion compared with RV size

2D RA volume: >34 mL/m² for men and >29 mL/m² for women
3D RA volume: >38 mL/m² for men and >34 mL/m² for women⁵¹

End-systolic RA:RV volume (or area) ratio ≥ 1.5 is suggestive of A-STR^2,3,43

4. Absence of significant tricuspid leaflet tethering

Single-plane measurement of coaptation height might underestimate leaflet tenting in case of asymmetric tethering

Absence of significant TV leaflet tethering is defined by

tenting height ≤ 9 mm
tenting area < 2.1 cm²
tenting volume <2.5 mL^43,52
leaflet angle < 15°²

5. RV conical remodelling with predominant enlargement of RV basal dimension

RV sphericity is a surrogate index reflecting conical (triangular) RV remodelling, and is calculated as (RV midventricular diameter × RV longitudinal diameter)/RV basal diameter

RV sphericity index < 55⁴⁹
RV midventricular diameter is normal (≤ 38 mm or ≤ 21 mm/m²)
RV basal diameter is enlarged (≥ 45 mm or ≥ 24 mm/m² for men, ≥ 40 mm and ≥ 20 mm/m² for women)⁴⁸

6. Preserved LV and RV systolic function

LVEF ≥ 50%
3D RVEF ≥ 50%
RVFWLS ≤ −20% (≤−23% for mid-wall strain)
RV TDI S’ ≥ 9 cm/s
FAC ≥ 35%
TAPSE > 17 mm^49,52

(in SR or rate-controlled AF and in earlier stages of the A-STR disease)

Table 1

Open in new tab

Proposed definition criteria for the atrial secondary tricuspid regurgitation phenotype

Definition criteria for A-STR	Recommended cut-offs and caveats
1. Clinically relevant STR (greater or equal to moderate)	Alternative causes of STR and the typical imaging features of primary TR should be adequately ruled out^a
	VC width (biplane) ≥ 3 mm PISA radius ≥ 5.5 mm PISA EROA ≥ 20 cm² PISA regurgitant volume ≥ 30 mL Regurgitant fraction ≥ 16%⁴⁹
2. Predominant TA dilation	Limits of normality for parameters of TA size depend on sex, body size, view, and timing of measurement during the cardiac cycle
	2D Echo measurements at end-diastole^48,50: Four-chamber TA diameter: >40 mm (22 mm/m²) for men and >35 mm (21 mm/m²) for women RV-focused TA four-chamber diameter: >41 mm (24 mm/m²) for men and >38 mm (22 mm/m²) for women 3D echo measurements at end-diastole by automated TV-specific software⁵⁰: Major (largest) TA diameter: >46 mm (27 mm/m²) for men and >43 mm (26 mm/m²) for women TA area: >13.8 cm² (8.4 mm/m²) for men and >11.7 cm² (6.9 mm/m²) for women⁵⁰ TA perimeter: >13.7 cm (8 cm/m²) for men and >12.5 cm (7.8 cm/m²) for women
3. Predominant RA dilation with increased end-systolic RA:RV ratio	RA dilation is not specific for A-STR, but rather its disproportion compared with RV size
	2D RA volume: >34 mL/m² for men and >29 mL/m² for women 3D RA volume: >38 mL/m² for men and >34 mL/m² for women⁵¹ End-systolic RA:RV volume (or area) ratio ≥ 1.5 is suggestive of A-STR^2,3,43
4. Absence of significant tricuspid leaflet tethering	Single-plane measurement of coaptation height might underestimate leaflet tenting in case of asymmetric tethering
	Absence of significant TV leaflet tethering is defined by tenting height ≤ 9 mm tenting area < 2.1 cm² tenting volume <2.5 mL^43,52 leaflet angle < 15°²
5. RV conical remodelling with predominant enlargement of RV basal dimension	RV sphericity is a surrogate index reflecting conical (triangular) RV remodelling, and is calculated as (RV midventricular diameter × RV longitudinal diameter)/RV basal diameter
	RV sphericity index < 55⁴⁹ RV midventricular diameter is normal (≤ 38 mm or ≤ 21 mm/m²) RV basal diameter is enlarged (≥ 45 mm or ≥ 24 mm/m² for men, ≥ 40 mm and ≥ 20 mm/m² for women)⁴⁸
6. Preserved LV and RV systolic function	Preserved bi-ventricular function criteria may not apply if the A-STR patient is evaluated during AF with relatively rapid ventricular response or in the late stages of severe to torrential A-STR (with/without significant A-SMR)
	LVEF ≥ 50% 3D RVEF ≥ 50% RVFWLS ≤ −20% (≤−23% for mid-wall strain) RV TDI S’ ≥ 9 cm/s FAC ≥ 35% TAPSE > 17 mm^49,52 (in SR or rate-controlled AF and in earlier stages of the A-STR disease)

Definition criteria for A-STR	Recommended cut-offs and caveats
1. Clinically relevant STR (greater or equal to moderate)	Alternative causes of STR and the typical imaging features of primary TR should be adequately ruled out^a
	VC width (biplane) ≥ 3 mm PISA radius ≥ 5.5 mm PISA EROA ≥ 20 cm² PISA regurgitant volume ≥ 30 mL Regurgitant fraction ≥ 16%⁴⁹
2. Predominant TA dilation	Limits of normality for parameters of TA size depend on sex, body size, view, and timing of measurement during the cardiac cycle
	2D Echo measurements at end-diastole^48,50: Four-chamber TA diameter: >40 mm (22 mm/m²) for men and >35 mm (21 mm/m²) for women RV-focused TA four-chamber diameter: >41 mm (24 mm/m²) for men and >38 mm (22 mm/m²) for women 3D echo measurements at end-diastole by automated TV-specific software⁵⁰: Major (largest) TA diameter: >46 mm (27 mm/m²) for men and >43 mm (26 mm/m²) for women TA area: >13.8 cm² (8.4 mm/m²) for men and >11.7 cm² (6.9 mm/m²) for women⁵⁰ TA perimeter: >13.7 cm (8 cm/m²) for men and >12.5 cm (7.8 cm/m²) for women
3. Predominant RA dilation with increased end-systolic RA:RV ratio	RA dilation is not specific for A-STR, but rather its disproportion compared with RV size
	2D RA volume: >34 mL/m² for men and >29 mL/m² for women 3D RA volume: >38 mL/m² for men and >34 mL/m² for women⁵¹ End-systolic RA:RV volume (or area) ratio ≥ 1.5 is suggestive of A-STR^2,3,43
4. Absence of significant tricuspid leaflet tethering	Single-plane measurement of coaptation height might underestimate leaflet tenting in case of asymmetric tethering
	Absence of significant TV leaflet tethering is defined by tenting height ≤ 9 mm tenting area < 2.1 cm² tenting volume <2.5 mL^43,52 leaflet angle < 15°²
5. RV conical remodelling with predominant enlargement of RV basal dimension	RV sphericity is a surrogate index reflecting conical (triangular) RV remodelling, and is calculated as (RV midventricular diameter × RV longitudinal diameter)/RV basal diameter
	RV sphericity index < 55⁴⁹ RV midventricular diameter is normal (≤ 38 mm or ≤ 21 mm/m²) RV basal diameter is enlarged (≥ 45 mm or ≥ 24 mm/m² for men, ≥ 40 mm and ≥ 20 mm/m² for women)⁴⁸
6. Preserved LV and RV systolic function	Preserved bi-ventricular function criteria may not apply if the A-STR patient is evaluated during AF with relatively rapid ventricular response or in the late stages of severe to torrential A-STR (with/without significant A-SMR)
	LVEF ≥ 50% 3D RVEF ≥ 50% RVFWLS ≤ −20% (≤−23% for mid-wall strain) RV TDI S’ ≥ 9 cm/s FAC ≥ 35% TAPSE > 17 mm^49,52 (in SR or rate-controlled AF and in earlier stages of the A-STR disease)

Definite A-STR diagnosis requires the fulfilment of all six criteria. Probable A-STR is defined by at least 4 criteria. Specific thresholds for parameters describing the geometry of right chambers and TV in A-STR are based on currently limited evidence, normative data, or TVARC document⁴⁹ and might be further refined by future dedicated studies on A-STR.

^aSee Supplementary material.

2D, two-dimensional; 3D, three-dimensional; AF, atrial fibrillation; A-SMR, atrial secondary mitral regurgitation; A-STR, atrial secondary tricuspid regurgitation; EROA, effective regurgitant orifice area; FAC, fractional area change; LV, left ventricular; LVEF, left ventricular ejection fraction; PISA, proximal isovelocity surface area; RA, right atrial; RV, right ventricular; RVFWLS, right ventricular free wall longitudinal strain; RVEF, right ventricular ejection fraction; SR, sinus rhythm; STR; secondary tricuspid regurgitation; TA, tricuspid annulus; TAPSE, tricuspid annular plane systolic excursion; TDI S’, tissue Doppler imaging systolic velocity; TR, tricuspid regurgitation; TV, tricuspid valve; VC, vena contracta.

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