Primary tricuspid valve regurgitation may be encountered in daily practice as a result of multiple etiologies. Described herein are the cases of 2 patients with severe primary tricuspid regurgitation. The underlying mechanism was posterior leaflet prolapse due to spontaneous chordae rupture in 1 case, and iatrogenic posterior leaflet tissue loss during removal of a permanent pacemaker in the other. Transthoracic and transesophageal echocardiography, which permit assessment of the tricuspid valve with multilevel imaging, are the techniques of choice for accurate detection and understanding of the etiology, the severity of valve regurgitation, and the determination of treatment options, in addition to providing assistance with timing and guidance during intervention. Three-dimensional echocardiography offers the ability to visualize the entire tricuspid valve and to identify which leaflets are affected by the pathology.