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Year : 2017  |  Volume : 1  |  Issue : 2  |  Page : 149-153

Transthoracic three-dimensional echocardiography of tricuspid valve

Department of Noninvasive Cardiology, Max Super Speciality Hospital, New Delhi, India

Date of Web Publication28-Aug-2017

Correspondence Address:
Rahul Mehrotra
Department of Noninvasive Cardiology, Max Super Speciality Hospital, 2, Press Enclave Road, Saket, New Delhi - 110 017
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jiae.jiae_36_17

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Imaging of the tricuspid valve (TV) by three-dimensional echocardiography (3DE) has not received much attention. 3DE allows users to visualize the whole TV apparatus from any perspective and enables a comprehensive evaluation of the leaflets. This review summarizes the current status of real time 3DE evaluation of TV morphology and function with its potential implications for TV disease assessment, as well as its clinical applications and limitations.

Keywords: Congenital tricuspid valve disease, three-dimensional echocardiography, tricuspid regurgitation, tricuspid stenosis, tricuspid valve

How to cite this article:
Mehrotra R, Kumar R. Transthoracic three-dimensional echocardiography of tricuspid valve. J Indian Acad Echocardiogr Cardiovasc Imaging 2017;1:149-53

How to cite this URL:
Mehrotra R, Kumar R. Transthoracic three-dimensional echocardiography of tricuspid valve. J Indian Acad Echocardiogr Cardiovasc Imaging [serial online] 2017 [cited 2020 Sep 29];1:149-53. Available from: http://www.jiaecho.org/text.asp?2017/1/2/149/213674

  Introduction Top

The right side of heart has historically received much less attention as compared to the left side. As a result, while much information is available regarding evaluation of left ventricle and mitral valve by real time three-dimensional echocardiography (RT-3DE), there is very little information on the evaluation of the right ventricle (RV) and the tricuspid valve (TV). This, in spite of the fact that the TV offers certain advantages in evaluation by echocardiography (anterior location, being close to the chest wall) and there is now an enhanced interest in its evaluation, owing to the greatly improved understanding about its role, even in the left heart disease. For example, it is known that the development of functional tricuspid regurgitation (TR) is directly associated with increased morbidity and mortality in patients with heart failure.[1],[2],[3],[4],[5] Data of this kind have led to increased interest in evaluation of the right heart and TV repair, especially at the time of concomitant surgery for the left-sided disease.[3] The assessment of TV is largely done by two-dimensional transthoracic echocardiography (2D-TTE) despite unique configuration of tricuspid leaflets and annulus, and the complex shape of RV. Imaging of the TV with 2D echocardiography (2DE) although quite straightforward and simple, is fraught with several limitations. Simultaneous visualization of the three TV leaflets is not possible with standard 2DE imaging views. Usually, only two leaflets can be imaged in any one 2DE view and determination of individual leaflet involvement in disease processes (especially the posterior leaflet) is quite challenging.[6] Multiple views are required, and thereafter mental reconstruction with the help of acquired images leads to the description of TV, clearly leaving scope for a lot of inconsistencies and inaccuracies. The planimetry of stenosed TV orifice, as done for the mitral valve in mitral stenosis, by 2DE is thus virtually impossible.

The advent of 3DE has revolutionized the field of echocardiography. 3DE permits the acquisition and display of cardiac structures in a manner not seen before. It provides better anatomical detail, relationship with neighboring structures and has greatly enhanced our understanding of cardiac structures. This is exemplified by the fact that 3DE is now the modality of choice for accurate assessment of mitral stenosis, mitral regurgitation, left ventricular volumes, and ejection fraction. On the right side of heart too, it is expected that the use of 3DE will overcome the limitations of 2DE and will allow a more objective and complete quantitative evaluation of TV anatomy and function [Table 1]. However, compared with the mitral and aortic valves, the TV has been studied much less with 3DE.[7],[8]
Table 1: Advantages of three-dimensional imaging of tricuspid valve

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We review here the current status of 3DE evaluation of TV morphology and function using TTE along with its clinical applications.

  Image Acquisition and Display of Tricuspid Valve Top

A thorough knowledge of the anatomical detail of the TV apparatus is imperative for good quality 3D imaging. The TV apparatus is composed of the annulus, leaflets, chordae, and papillary muscles. The tricuspid annulus is much larger than other valves (8–12 cm2). 3DE assessment of the TV has demonstrated that the tricuspid annulus is saddle shaped and not a planar structure, similar to the mitral valve.[9],[10],[11] Out of the three leaflets (anterior, septal, and posterior), the anterior tricuspid leaflet is the largest and is attached along the anterolateral surface of the tricuspid annulus. The septal leaflet attaches along the interventricular surface and the posterior leaflet along the posterior portion of the annulus. Tricuspid leaflets are also much thinner and more translucent than those of the mitral valve, making it difficult to image by 3DE. There are usually three papillary muscles from which a variable number of chordae are attached to leaflets. The largest is the anterior papillary muscle (attached to the anterior wall of the RV with its chordae inserted to the anterior and posterior cusps of the valve). The posterior papillary muscle is often divided and attaches to the inferior wall of the RV with its chordae inserting into the posterior and septal cusps of the valve while the smallest and variable is the small group of septal papillary muscles. They are attached to the interventricular septum and the chordae insert to the septal and anterior cusps. A large number of variations are possible in this anatomy including in the number, size, position of leaflets, chordae, and papillary muscles. This complex, large, valve apparatus along with the complex shape of the RV pose a big challenge in good quality 3D imaging of this valve.

Image acquisition

As we are aware, 2DE imaging of the TV requires image acquisition from multiple planes to visualize all the structures of the valve.[6] With 3DE also, the three windows to be used are the parasternal, apical, and subcostal. However, when trying to image a cardiac structure with RT-3DE, we have to take into account the point spread function of the system.[12] The point spread function describes the response of an imaging system to any point input. It results in blurring of the point object when visualized and the degree of blurring depends on the plane used. In the 3DE systems being used currently, it is minimum in the axial (y) plane (0.5 mm), 2.5 mm in the azimuthal (y) plane, and maximum in the elevational (z) plane (3 mm). Therefore, for imaging of the TV, least blurring will be observed in the parasternal image (which uses the axial and azimuthal plane) and maximum blurring will be seen with the apical view which uses lateral and elevational planes. However, it is prudent to obtain both the parasternal views (inflow and short axis) along with the apical view (RV focused) in all patients for acquiring 3D images of the TV. Subcostal approach is generally not utilized in adults. 3D TTE imaging of the TV allows visualization of all aspects of the TV either from a single, full volume data set and permits a detailed examination of a part of the TV apparatus, using a narrower imaging acquisition mode (but with higher resolution).[6],[13],[14] After acquiring the images in live 3D zoom mode or the full volume mode, postprocessing and cropping are done using the standard approaches-box cropping or free plane cropping to remove the unwanted structures, while preserving the TV. Optimal gain settings (slightly over gain for TV) are to be used along with breath holding (for full volume datasets, to avoid stitch artifacts). Slicing function available with most 3D platforms can also be used for this purpose in conjunction with cropping to obtain desired slices of the TV [Table 2].
Table 2: Steps for three-dimensional image acquisition of the tricuspid valve

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In patients with good 2DE images, assessment of TV anatomy and function with RT-3DE is feasible in around 90% of normal subjects by TTE. Once good quality images are obtained, the display of the complete TV en face image is done using the standard recommendation.[12] To standardize the display and for helping in comparing of serial images, it is recommended that the TV septal leaflet should be at the 6 O' clock position from both-RA as well as the RV perspective (along with the interatrial and interventricular septum, respectively) [Figure 1] and [Figure 2]. The commissures and all the three leaflets can be seen in a single view with this image. This enables the planimetry of the stenosed orifice, apart from helping in accurately localizing the disease process to a leaflet (prolapse, perforation, and vegetation) or for localization of regurgitant jets.[14]
Figure 1: Three-dimensional full volume of the tricuspid valve from the right atrial perspective. The three leaflets of the valve are marked - (1) septal leaflet, (2) anterior leaflet, and (3) posterior leaflet. IAS: Interatrial septum, is at 6 O' clock position as per recommendation

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Figure 2: Three-dimensional full volume of the tricuspid valve from the right ventricle perspective. The three leaflets of the valve are marked – (1) septal leaflet, (2) anterior leaflet, and (3) posterior leaflet. IVS: Interventricular septum, is at 6 O' clock position as per recommendation

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3DE appears simple and is very informative but requires learning and practice. 3DE of TV is much more difficult than that of the left ventricle and mitral valve owing to the reasons discussed earlier.

  Clinical Applications Top

As mentioned earlier, 3DE of the TV has provided useful new insights into TV anatomy. This information is very useful in localizing the pathology and planning treatment strategies. In a study of 29 patients with different TV pathologies, where both 3DE and 2DE of the TV were compared, 3DE provided incremental diagnostic information over 2DE with regard to etiology and location of the abnormal leaflet segments.[15] It has also been observed with the use of 3DE, that with the development of functional TR, the TV annulus (which has a saddle shape) becomes more and more planar, and circular, expanding mostly along the anterolateral border. This will have useful implications for the design of TV repair rings and surgical procedures.[9],[10]

Similarly, 3DE has provided useful mechanistic insights into TR in patients with pulmonary hypertension[16] congenital heart disease,[17],[18],[19] patients with tricuspid stenosis (TS), and in patients with leads traversing the TV (pacemaker or cardioverter defibrillator) and with disease states like carcinoid heart disease. Few of the important clinical uses are discussed below.

Tricuspid regurgitation

TR is mostly secondary due to impaired valve coaptation caused by a dilation of the RV and/or of the tricuspid annulus. However, a number of primary disease processes can affect the TV complex directly and lead to TR. Rheumatic heart disease, infective endocarditis, Ebstein's anomaly, atrioventricular canal defect, carcinoid syndrome, endomyocardial fibrosis, and catheter placement in the right heart chambers are few common causes.

RT-3DE can be useful for a better characterization of TV lesions in each of these primary etiologies. For example, in rheumatic involvement of the TV, regurgitation occurs as a result of deformity, shortening and retraction of one or more leaflets of the TV as well as shortening/fusion of the chordae tendineae and papillary muscles. 2DE usually is able to detect thickening and distortion of the leaflets but cannot provide a detailed assessment of the subvalvular apparatus. The full volume data set from apical window provides a comprehensive assessment of the whole TV apparatus which can then also be examined from different perspectives. The “en face” view of the TV obtained by 3DE enables visualization of the commissural fusion which is helpful to establish a correct diagnosis of rheumatic etiology of TR. Like the mitral valve, myxomatous disease of the TV is nicely demonstrated by 3DE as bulging or protrusion of one or more segments of a single or multiple TV leaflets. Besides, chordal rupture can also be assessed in the same view. In carcinoid disease, 3DE can clearly show the regions of ineffective leaflet coaptation and the absence of commissural fusion, helping to differentiate it from rheumatic process.

In an elegant study of 87 patients with pacemakers or implantable cardioverter-defibrillator (ICD) leads, Seo et al. demonstrated that 3DE accurately identified the lead position as it traversed the TV, resulting, at times, in TR.[20] They found that the lead impingement against any tricuspid leaflet was associated with significant TR, while a lead traversing within one of the commissures or being mobile as it crossed the TV through its center was associated with least TR [Figure 3]. This kind of information will be very useful in the future in performing 3DE guided pacemaker and ICD implantations to reduce the incidence of lead associated TR.
Figure 3: Three-dimensional full volume of the tricuspid valve from the right ventricle perspective. The three leaflets of the valve are marked – (1) septal leaflet, (2) anterior leaflet, and (3) posterior leaflet. IVS: Inter-ventricular septum. The pace maker lead P, marked by arrow is seen passing through the commissure between the septal and posterior leaflets

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Estimating the severity of TV regurgitation using color flow RT-3DE is not yet well developed for routine clinical use, hence not discussed here. Velayudhan et al.[21] studied the area of the vena contracta of the TR jet by cropping the RT-3DE color Doppler data set with imaging planes exactly parallel to the TV orifice. They found a poor correlation between the area of the vena contracta obtained by RT-3DE and its width measured by 2DE. This clearly proved that the vena contracta of the regurgitant tricuspid jet routinely obtained by 2DE is an oversimplification. More data are needed before cut-off values for severity of TR by color 3DE can be given for routine use.

  Tricuspid Stenosis Top

TS in adults is almost always due to rheumatic heart disease and in association with mitral and/or aortic valve involvement. Carcinoid heart disease can also lead to TS.

As mentioned earlier, a major limitation of 2DE in TS is the inability to get an en face view of the TV orifice for planimetry of stenotic valve area and visualize commissural fusion. Using RT-3DE, the orifice of TV stenosis can be clearly visualized and planimetry can be performed. 3DE thus provides incremental information to that obtained by 2DE and Doppler parameters for assessment of severity of TS.

  Congenital Tricuspid Valve Disease Top

Ebstein's anomaly is the most common congenital defect of the TV in adults. Although 2DE can show the characteristic displacement of the septal leaflet and the redundant and elongated anterior leaflet, the complex anatomy of the disease and the mechanisms of valve regurgitation are very difficult to assess. In adult patients with Ebstein's anomaly of the TV, Patel et al.[22] reported that RT-3DE was particularly useful in delineating the chordal attachment of the three leaflets of the TV. This was made possible by systematic cropping and sectioning of the RT-3DE data sets, which is not possible with 2D imaging. In addition, an en face view of the valve obtained with RT-3DE can be used to measure the leaflet surface areas, and to visualize the regions of ineffective leaflet coaptation [Figure 4]. Moreover, RT-3DE can be useful in evaluating the size of the functional RV, and to obtain an en face view of the vena contracta for estimating severity of TR. These are currently possible with specific software packages only, and not routinely available.
Figure 4: Three-dimensional full volume of the tricuspid valve from the right ventricle perspective in a patient with Epstein's anomaly. The three leaflets of the valve are marked (1) septal leaflet, (2) anterior leaflet, and (3) posterior leaflet. IVS: Interventricular septum. There is a large central area of noncoaptation leading to severe tricuspid regurgitation

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  Infective Endocarditis Top

TV endocarditis is usually seen in young intravenous drug abusers. The size of vegetation is an important predictor of embolic events, decision for surgery and for predicting response to treatment. 2DE derived measurements are routinely used to determine the vegetation size. However, most vegetations are irregularly shaped, making it difficult to accurately image or select the largest diameter by 2D imaging. RT-3DE images the entire volume of a vegetation allowing for accurate measurements in multiple planes and has been shown to be a useful measure in addition to routine 2D imaging. Limitations of 3DE and future perspectives.

Despite all the available data supporting the use of RT-3DE to assess TV morphology and function, especially in patients who are candidates for cardiac surgery for left-sided diseases, this technique has not been integrated into the clinical routine. There are several reasons to explain this: some pertaining the 3D technique per se, while others are related to the application of the technique to the study of the TV.

At present, there is no evidence that 3D assessment of TV anatomy and function may improve surgical results. However, clinical research is active in this field and results are expected soon.

The lack of standardized measures and specific software to quantitate tricuspid annulus and leaflet size/shape, as it has been developed for the mitral valve, is another limitation. However, the increasing interest for the TV assessment by 3DE by both echocardiographers and surgeons will fuel development and implementation of such a tool.

To summarize, comprehensive imaging of the TV by 2DE is hampered by inability to visualize all three leaflets simultaneously. Conversely, RT-3DE provides a unique tool for a detailed assessment of morphology and function of the entire TV complex. Understanding the anatomy and the pathophysiological mechanisms underlying the various TV diseases will provide the basis for surgical planning to tailor the intervention to patients' needs. More and more use of 3DE by echocardiographers and undertaking of studies with the use of 3DE for TV evaluation will help generate useful data and pave the way for development of this modality also. Till quantitative assessment software is made available for TV, 3D images of the TV should be obtained and utilized in different disease states.

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Conflicts of interest

There are no conflicts of interest.

  References Top

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Dreyfus GD, Corbi PJ, Chan KM, Bahrami T. Secondary tricuspid regurgitation or dilatation: Which should be the criteria for surgical repair? Ann Thorac Surg 2005;79:127-32.  Back to cited text no. 3
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Muraru D, Badano LP, Sarais C, Soldà E, Iliceto S. Evaluation of tricuspid valve morphology and function by transthoracic three-dimensional echocardiography. Curr Cardiol Rep 2011;13:242-9.  Back to cited text no. 13
Badano LP, Agricola E, Perez de Isla L, Gianfagna P, Zamorano JL. Evaluation of the tricuspid valve morphology and function by transthoracic real-time three-dimensional echocardiography. Eur J Echocardiogr 2009;10:477-84.  Back to cited text no. 14
Pothineni KR, Duncan K, Yelamanchili P, Nanda NC, Patel V, Fan P, et al. Live/real time three-dimensional transthoracic echocardiographic assessment of tricuspid valve pathology: Incremental value over the two-dimensional technique. Echocardiography 2007;24:541-52.  Back to cited text no. 15
Sukmawan R, Watanabe N, Ogasawara Y, Yamaura Y, Yamamoto K, Wada N, et al. Geometric changes of tricuspid valve tenting in tricuspid regurgitation secondary to pulmonary hypertension quantified by novel system with transthoracic real-time 3-dimensional echocardiography. J Am Soc Echocardiogr 2007;20:470-6.  Back to cited text no. 16
Abadir S, Léobon B, Acar P. Assessment of tricuspid regurgitation mechanism by three-dimensional echocardiography in an adult patient with congenitally corrected transposition of the great arteries. Arch Cardiovasc Dis 2009;102:459-60.  Back to cited text no. 17
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Takahashi K, Inage A, Rebeyka IM, Ross DB, Thompson RB, Mackie AS, et al. Real-time 3-dimensional echocardiography provides new insight into mechanisms of tricuspid valve regurgitation in patients with hypoplastic left heart syndrome. Circulation 2009;120:1091-8.  Back to cited text no. 19
Seo Y, Ishizu T, Nakajima H, Sekiguchi Y, Watanabe S, Aonuma K, et al. Clinical utility of 3-dimensional echocardiography in the evaluation of tricuspid regurgitation caused by pacemaker leads. Circulation 2008;72:1465-70.  Back to cited text no. 20
Velayudhan DE, Brown TM, Nanda NC, Patel V, Miller AP, Mehmood F, et al. Quantification of tricuspid regurgitation by live three-dimensional transthoracic echocardiographic measurements of vena contracta area. Echocardiography 2006;23:793-800.  Back to cited text no. 21
Patel V, Nanda NC, Rajdev S, Mehmood F, Velayudhan D, Vengala S, et al. Live/real time three-dimensional transthoracic echocardiographic assessment of Ebstein's anomaly. Echocardiography 2005;22:847-54.  Back to cited text no. 22


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

  [Table 1], [Table 2]


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