The most common etiology of TR is secondary (functional), and its incidence is approximately 90% among patients with TR. The two main types of tricuspid regurgitation (TR) are primary and secondary (functional). Pathophysiology of Tricuspid Regurgitation (TR) The tricuspid annulus is a dynamic structure and D shaped, with a larger semicircular C-shaped segment correlating with the RV free wall and a shorter and straighter segment correlated to the septum. The posterior papillary muscle can be bifid or trifid, and the attached chordae support posterior and septal leaflets. This papillary muscle sometimes joined by the moderator band. Anterior papillary muscle is the largest, and attached chordae support the anterior and posterior leaflets. Usually, there are two papillary muscles, anterior and posterior, with a third septal papillary muscle, which is variable. The coaptation length is 5 to 10 mm, allowing more valve area available in case of annular dilatation before failure to coapt. The coaptation point of the leaflets is at or below the level of the annulus. The posterior (or attitudinally inferior) leaflet is the shortest circumferentially.

Septal leafet is the least mobile and attached to the septum less than 10 mm apically from the septal insertion of the anterior mitral leaflet, a distinguishing feature helpful in diagnosing Ebstein anomaly when it is tethered to the right ventricular wall giving it an echocardiographic appearance of greater than 10 mm apical attachment and causing atrialization of the RV with severe TR. The anterior (or attitudinally anterosuperior) leaflet is the largest of the three leaflets with the greatest motion. There are reported variants of the TV with two or more than three cusps. The mean pressure gradient across the TV is less than 2 mmHg, and peak velocity across the valve is less than 1 m/s due to the large size of the valve and lower pressures on the right side of the heart. The tricuspid valve complex consists of the leaflets, annulus, chordae, papillary muscles, and attached right ventricle segment.

It consists of three leaflets, namely septal, anterior and posterior, and has a normal valve area of 7-9 cm2. Of all the valves in the heart, the tricuspid valve (TV) is the largest and most apically placed between the right atrium (RA) and the right ventricle (RV).

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