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doi:10.1093/ejechocard/jep044
REVIEW PAPER
KEYWORDS Assessment of tricuspid valve (TV) function plays an important role in a number of clinical disease
Echocardiography; states, including left-sided valve disease and heart failure. However, the TV is a complex structure
Three-dimensional; that, unlike the aortic and mitral valve, it is not possible to visualize in one cross-sectional view
Real-time; using either transthoracic or transoesophageal two-dimensional echocardiography (i.e. imaging all
Tricuspid valve; three TV leaflets and their attachment in the annulus simultaneously). Conversely, three-dimensional
Tricuspid insufficiency; echocardiography allows users to visualize the whole TV apparatus from any perspective. This may sig-
Tricuspid stenosis; nificantly improve our understanding of the pathophysiological mechanisms underlying the various TV
Tricuspid regurgitation; diseases and functional tricuspid regurgitation, and potentially suggest ways to improve surgical treat-
Surgery ment. This review details the current status of real-time three-dimensional echocardiography evalu-
ation of TV morphology and function with its clinical applications and limitations.
Introduction two leaflets can be imaged in one 2DE view and determi-
nation of individual leaflet involvement (especially the pos-
Function of the tricuspid valve (TV) plays an important role in terior leaflet) is challenging when a disease process is
several heart diseases, including left-sided valve disease and present.7 This limitation can be partially overcome with an
heart failure, and the development of functional tricuspid anterior to posterior sweep to see both the anterior and
regurgitation is directly associated with increased morbidity the posterior leaflets using the apical 4-chamber or subcos-
and mortality.1–5 These data have increased motivation to tal view. Afterwards, the echocardiographer starts a difficult
repair functional tricuspid regurgitation, especially at the mental process to reconstruct a stereoscopic image of the
time of concomitant surgery for left-sided disease.3 TV based on the interpretation of the multiple tomographic
However, the unsatisfactory results of current approaches images obtained with the sweep. Sometimes, the mental
suggest an incomplete understanding of the underlying mech- exercise of reconstruction may be inadequate to obtain a
anisms.3,6 As in the case of mitral regurgitation, a better precise diagnosis even for an experienced observer, particu-
understanding of the pathophysiological mechanisms under- larly when dealing with complex valvular abnormalities.
lying functional tricuspid regurgitation could potentially The advent of real-time three-dimensional echocardiogra-
suggest ways to improve surgical treatment. phy (RT-3DE) may obviate for this exercise by allowing a
The assessment of the TV is mostly done by two- more objective and quantitative evaluation of TV anatomy
dimensional echocardiography (2DE) despite unique con- and function that would reduce the subjectivity in the
figuration of tricuspid leaflets and annulus, and anatomic interpretation of images. However, compared with the
complexity of the right ventricle. As a result, simultaneous mitral and aortic valves, the TV has been less widely
visualization of the three TV leaflets has not been achieved studied with 3D echocardiography.8,9
routinely from standard 2DE imaging views. Usually, only This review details the current status of RT-3DE evaluation
of TV morphology and function with its clinical applications
* Corresponding author. Tel: þ39 0432 552444; fax: þ39 0432 482353. and limitations.
E-mail address: badano.luigi@aoud.sanita.fvg.it; lbadan@tin.it
Published on behalf of the European Society of Cardiology. All rights reserved. & The Author 2009.
For permissions please email: journals.permissions@oxfordjournals.org
478 L.P. Badano et al.
Figure 2 Normal tricuspid valve leaflets visualized by real-time three-dimensional echocardiography from atrial (left panel) and ventricular
side (right panel). ATL, anterior tricuspid leaflet; Ao, aorta; MV, mitral valve, PTL, posterior tricuspid leaflet; STL, septal tricuspid leaflet.
Figure 5 Comparison of tricuspid annulus diameter measurements by two-dimensional (A) and three-dimensional echocardiography (B and
C ). When the measurement taken by two-dimensional echo is reported on the three-dimensional image of the tricuspid annulus (B) it can be
realized that it does not represent the minor nor the major diameter of the annulus and underestimates both (C).
its free-wall distance. This latter finding has an important with normal tricuspid annulsus size at RT-3DE.22 Conversely,
clinical implication. calculation of tricuspid annulus fractional shortening yielded
Matsunaga et al.20 demonstrated that pre-operative tri- the same results using 2DE and RT-3DE.22 This is because the
cuspid annular dilation was associated with the develop- extent of underestimation of tricuspid annulus diameter
ment of late post-operative tricuspid regurgitation after made by 2DE is comparable in diastole and in systole.
repair of ischaemic mitral regurgitation. Dreyfus et al.3 In addition to tricuspid annulus shape, size, and function,
reported that when the decision to perform tricuspid annu- RT-3DE allows to assess TV leaflet geometry in functional tri-
loplasty was based on the extent of tricuspid annular cuspid regurgitation. In patients with pulmonary hyperten-
dilation rather than the degree of tricuspid regurgitation sion (i.e. right ventricular to right atrium gradient
at the time of surgery, the long-term outcome of patients 30 mmHg), Sukmawan et al.23 reported that patients
was improved. Reference measures for TV repair include tri- with tricuspid regurgitation showed a tethering of tricuspid
cuspid annulus size .2.1 cm/m2 and tricuspid annulus frac- leaflets into the right ventricle. The measured TV tenting
tional shortening ,25%.21 However, both Matsunaga and volume was linearly correlated with right ventricular
Dreyfus used 2DE for decision-making surgery and this may volume and with TV regurgitant jet area.
have led to some inaccuracies in measuring the true At the moment there are no data supporting the use of
annular size. RT-3DE in selecting patients to be addressed to surgical
Anwar et al.22 demonstrated that the tricuspid annulus repair of functional tricuspid regurgitation. However as in
shape is not circular but oval, with a minor and a major the case of mitral regurgitation, an improved assessment
diameter, both in normal sized and in dilated annulus. In of valve anatomy and understanding of the pathophysiologi-
addition, they showed that the currently used tricuspid cal mechanisms underlying the TV regurgitation could
annulus diameters measured with 2DE (both measured in suggest new and more effective techniques for TV repair.
apical 4-chamber view and in parasternal short-axis view) Finally, RT-3DE can help in estimating the severity of TV
systematically underestimated the actual tricuspid annulus regurgitation using colour flow. Velayudhan et al.24 demon-
size (Figure 5). As a consequence, 65% of patients with strated the feasibility of obtaining the area of the vena con-
normal tricuspid annulus diameter at 2DE showed grade tracta of the tricuspid regurgitant jet by cropping the
1–2 tricuspid regurgitation compared with 30% of patients RT-3DE colour Doppler data set with imaging planes
482 L.P. Badano et al.
Tricuspid stenosis
Tricuspid stenosis is uncommon in adult patients. In nearly
all cases it is due to rheumatic disease in association with
rheumatic mitral and/or aortic valve involvement. Carcinoid
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