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Received: 7 July 2018 Revised: 28 July 2018 Accepted: 6 August 2018 DOI: 10.1111/echo.14130
Assessment of tricuspid valve by two-and three-dimensional echocardiography with special reference to percutaneous repair and prosthetic valve implantation procedures Christopher S. G. Murray MD1 | Ahmed Y. Salama MD2 | Raziye E. Akdogan MD2 | Serge Harb MD3 | Tamanna Nahar MD4 | Navin C. Nanda MD2 1 Department of Internal Medicine, Harlem Hospital Center/Columbia University, New York, New York 2
Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama 3
Section of Cardiovascular Imaging, Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio 4
Section of Cardiology, Department of Internal Medicine, Harlem Hospital Center/ Columbia University, New York, New York Correspondence Navin C. Nanda, Heart Station/ Echocardiography Laboratories, University of Alabama at Birmingham, Birmingham, AL. Email:
[email protected]
Moderate-to-severe tricuspid regurgitation affects approximately 1.6 million people in the United States. An estimated 8000 patients will undergo tricuspid surgery annually, leaving a large number of patients with this condition untreated. Many of these individuals who are not referred for surgery engender a large unmet clinical need; this may be primarily due to the surgical risk involved. In persons who are categorized as high-risk surgical candidates, percutaneous procedures present a viable alternative. The majority of developmental attention as regards percutaneous approaches has been focused on the aortic and mitral valves recently, but few data are available about the feasibility and efficacy of minimally invasive tricuspid valve treatment. We review the usefulness of two-and three-dimensional echocardiography in the assessment of the tricuspid valve with special reference to recent interest in percutaneous repair and prosthetic valve implantation procedures for severe functional tricuspid regurgitation. KEYWORDS
echocardiography, three-dimensional echocardiography, transcatheter tricuspid valve repair, transcatheter tricuspid valve-in-valve, tricuspid regurgitation, tricuspid valve, twodimensional echocardiography
1 | I NTRO D U C TI O N
referral, conservative medical management has reached a stage of futility after a protracted clinical course culminates in right-sided
It was accepted for some time that avoiding tricuspid valve (TV) re-
heart failure and incapacitation.4,5
pair in functional tricuspid regurgitation (FTR) that was due to dis-
In patients who are assessed as high-risk candidates for TR sur-
ease of the left heart was feasible, as it was erroneously thought
gery, minimally invasive percutaneous procedures are often consid-
that it would disappear or considerably reduce in severity as soon
ered as an alternative, with a number of transcatheter (TC) devices
as the left heart disease had been addressed. Subsequently, there
having been developed to manage TR. It should be noted here that
has been evidence favoring a more assertive surgical approach to
FTR will represent the most likely etiology of TR, accounting for some
this valvopathy; recent guidelines recommend surgical attention
75% of same, which is where these devices will have utility; other
be paid to the TV when FTR or nonsevere TR with a dilated tricus-
causes of organic TR may find a minimally invasive TC approach less
pid valve annulus (TVA) accompanies left-sided disease; and at the
suitable.6 A review of current literature does not yield any instances
1–3
Acceptable results
of standard TC approaches to primary TR. If severe TR is due to en-
have been reported postoperatively. However, these procedures are
docarditis, rheumatic disease, leaflet flail, or prolapse, then a standard
fraught with high morbidity and mortality as there may be TR recur-
surgical approach may be more appropriate for the patient. It must
rence after surgery, as well as the fact that, at the time of surgical
be borne in mind that, currently, minimally invasive therapies geared
time, the latter is being operatively addressed.
Echocardiography. 2018;35:1419–1438.
wileyonlinelibrary.com/journal/echo © 2018 Wiley Periodicals, Inc. | 1419
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at addressing TR are still in a formative stage, with limited supporting data to date. After the left-sided valvular surgery is undergone, the development of worsening preexisting TR long afterward is not uncommon, with an estimated incidence of 27% in one study,7 and is closely associated with a poor prognosis, the presence of preoperative atrial fibrillation (AF) being identified as the only independent predictor of same.8,9 It should also be noted that FTR is frequently associated with functional ischemic mitral regurgitation (MR); after the mitral valve (MV) has been replaced, many patients will subsequently develop clinically significant TR, and the prevalence of this sequela increases in proportion to time.10 It is also prudent to note that, in patients with less than severe TR, the condition may progress after surgery if the TV is not intraoperatively addressed, with one study reporting a worsening of TR from grade 2 preoperatively to grade 3 (out of 4) postoperatively in 37% of the patients being followed.11
• FTR presents the cardiologist and cardiac surgery team with the dilemma of low post-op survival • Oftentimes, the FTR may be secondary to left-sided disease which, when fixed alone, may worsen the FTR • TC devices geared to treat left-sided disease may subsequently worsen the preexisting right-sided valvulopathy also. • Several minimally invasive percutaneous options are now available for severe FTR treatment, when open surgery would not be feasible. • The echocardiographic modalities available are essential in imaging the TV, and their necessity and use in restorative procedures will be further looked at here.
There is a clear reduction in survival associated with significant TR as well as with postoperative FTR12 This fact underscores the importance of the exploration of alternatives to surgery in these
cardiac cycle and reconstructed with software, revealing a nonpla-
patients, which should inform prognostic survival. The current
nar, elliptical-shaped annulus in the healthy patient. 21 It is superiorly
standard surgical treatment of FTR remains annuloplasty of the
(atrially) displaced in the anteroseptal portion near the right ventri-
TV. The reasoning behind this is that, if the annular dimensions
cle (RV) outflow tract and aortic valve (AV) and apically displaced in
can be corrected, then this should cause the leaflets to coapt, and
the posteroseptal portion near the coronary sinus (CS) inflow. 21,22
hence, the anteroseptal diameter of the TV would be reduced and
A normal TVA area in healthy subjects ranges from 9.72 ± 2.08 to
this would oppose further annular dilatation. There is the surgical
9.94 ± 2.33 cm2; this area increases significantly during atrial systole
option of suture repair vs use of a prosthetic ring; the latter would
and in late systole/diastole, as does the circumference. 21,23 Normal
seem to be more durable as studies have shown that there is sig-
TVA diameter in adults is 28 ± 5 mm in the 4-chamber view, with
nificant reduction in recurrent TR after surgery with this surgical
significant TVA dilatation being defined by a diastolic diameter of
method.13,14 More persons will likely die after surgery on the TV
>21 mm/m2. It should also be noted that findings in favor of signifi-
15,16
This evidence has led
cant TR include a systolic TVA diameter of >32 mm and a diastolic
to the early prophylactic intervention of combined tricuspid repair
diameter of >34 mm. 24 The TV apparatus can be divided into several
at the time of left-sided valve procedures. With the increase in TC
components: the fibrous annulus, anterior leaflet (AL), septal leaflet
options for left-sided valvulopathies, the TV once again will not be
(SL) and posterior/inferior leaflet (PL/IL), anterior and posterior papil-
simultaneously addressed in these cases, causing a similar dilemma
lary muscles, and the chordal attachments. 21,25–29 The annular plane
to represent itself, and this brings into sharp focus the need for
of the TV is nearly vertical and approximately 45° from the sagittal
enhancement of minimally invasive percutaneous options for repair
plane. The 3 TV leaflets vary in circumferential and radial size; the AL
of TR.17–19
being the longest radial leaflet with the largest area and greatest mo-
than after surgery on any other valve.
Currently, there are a number of TC devices either in use or at trial
tion. The SL is the shortest in the radial direction, least mobile and
stage; the very nature of these devices dictates an intimate knowl-
attached to the TVA and is inserted into the septum ≤ 8 mm apical
edge of both the anatomy and imaging techniques. There must be a
to the septal insertion of the anterior mitral leaflet. The PL may have
full understanding of transthoracic (TTE) and transesophageal (TEE)
multiple scallops and is circumferentially the shortest.
echocardiography utilizing both two-dimensional (2D) and three-di-
The size and shape of the TVA vary, and this can change ana-
mensional modalities, as well as intracardiac echocardiography (ICE)
tomic landmarks for visualization of the leaflets. The commissure
in some cases to be able to adequately assess the state of the TV, as
between the SL and PL is usually located near the entrance of the
well as in preprocedural planning, intraprocedural guidance, post-
CS to the right atrium (RA). The anterior and posterior papillary mus-
procedural reassessment, and in detection of residual disease. 20
cles are distinct, and a third one is variable. The largest is typically the anterior papillary muscle, with chordae supporting the AL and
2 | A LO O K AT TH E A N ATO M Y O F TH E TR I CU S PI D VA LV E
PL. The moderator band may join the anterior papillary muscle. The posterior papillary muscle is often bifid or trifid, supporting the PL and SL leaflets. It should also be noted that, in some patients, the PL/IL leaflet may be absent or rudimentary and, in some patients,
The TV, which is the largest valve, is oval in shape and config-
clefts have been reported in the AL.
ured like a saddle; this configuration has been studied in a recent
In addition to 2D, 3D echocardiography has been integral in the
3DTEE study, during which the annulus was mapped throughout the
current understanding of TV anatomy. 21,25,30,31 There are multiple
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etiologies of FTR, primarily pulmonary hypertension, RV dilatation, and RV failure.
26
3 | I M AG I N G O F TH E TR I CU S PI D VA LV E
Isolated dilatation of the TVA, otherwise known
as isolated or idiopathic TR, has also been recently recognized.32–34
Visualization of the TV should be performed by 2DTTE/3DTTE and
Functional dilatation results in the valve becoming more circular and
if indicated by both 2D and 3DTEE imaging techniques, to evaluate
planar, due to the dilatation occurring along AL and PL attachments
both the valve35 as well as the chamber dimensions.36,37 Much more
and sparing the SL attachment30 (Tables 1, 2, Figures 1–4).
recently, the technique of 3D printing, which involves image-guided creation of replicas of pertinent structures of the heart and the valve apparatus, has been conceptualized and is still being further developed; this is primarily targeted at anatomically challenging cases, to
• The anatomy of the TV is unique as it is largest in comparison with the other valves. • There is considerable variability in size and dimensions of the TV. • These characteristics of the TV make the prospect of percutaneous repair somewhat technically challenging.
TA B L E 1 Causes of organic tricuspid valve involvement Rheumatic valve disease: commissural fusion, thick TV leaflets with restricted mobility, thickened and shortened chordae, stenosis, and/or regurgitation Infective/marantic endocarditis, masses, and thrombi: vegetations seen as thickening or mobile masses involving TV Myxomatous degeneration/TV prolapse: Leaflets are thickened, redundant, and prolapse beyond the annular plane into right atrium TV or RV papillary muscle injury: (direct/indirect chest wall trauma, pacemaker, or ICD lead-induced, during endomyocardial biopsy, RV infarction) Congenital: Ebstein anomaly (adherence of TV tissue to RV wall/ ventricular septum), TV atresia, TV clefts, TV dysplasia, double- orifice TV, and unguarded TV orifice Carcinoid syndrome: thickened, restricted TV leaflets. Carcinoid deposits on chamber/IVC walls
F I G U R E 1 Schematic diagram of tricuspid valve. AL = anterior leaflet; Ao = aorta; AZ = azygos vein; CS = coronary sinus; DA = descending aorta; E = esophagus; LA = left atrium; LLPV = left lower pulmonary vein; LPA = left pulmonary artery; LV = left ventricle; MPA = main pulmonary artery; MV = mitral valve; PL = posterior leaflet; RPA = right pulmonary artery; RA = right atrium; RV = right ventricle; SL = septal leaflet. Reproduced with permission from Maxted et al40
Loeffler syndrome: thickened TV, may respond to steroids Drug (anorectic drugs, dopamine agonists, ergot derivatives, and ecstasy) or radiation induced ICD = intracardiac defibrillator; RV = right ventricle; TV = tricuspid valve.
TA B L E 2 Causes of functional tricuspid regurgitation Primary/secondary pulmonary hypertension: causing RV/RA/TVA dilatation Cardiomyopathy of RV: dilated, ischemic, and arrhythmogenic RV dysplasia Stenosis of pulmonic valve/pulmonary artery Left-sided pathologies: LV dysfunction or mitral/aortic stenosis or regurgitation resulting in pulmonary hypertension Left-to-right shunt: atrial septal defect, ventricular septal defect, and anomalous pulmonary venous return Chronic atrial fibrillation: resulting in LA/RA dilatation Isolated TV annular dilatation LA = left atrium; LV = left ventricle; RA = right atrium; RV = right ventricle; TVA = tricuspid valve annulus.
F I G U R E 2 Apical four-chamber view showing a dilated tricuspid valve annulus (TVA). Other abbreviations are as in Figure 1. Reproduced with permission from Nanda NC. Atlas of Color Doppler Echocardiography. Philadelphia: Lea and Febiger; 1989:200
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better facilitate procedural planning. Imaging modalities will now be
detected opposite the AL in the RV inflow view. However, the PL or
looked at in more detail in the assessment of severe FTR.
IL is most reliably identified in the RV two-chamber view, since the plane passes through the inferior aspect of the RV free wall adjacent
4 | T WO - D I M E N S I O N A L EC H O C A R D I O G R A PH Y O F TH E TR I CU S PI D VA LV E
to the diaphragm.37 In our experience, the most reliable approach to assess RV and hence pulmonary artery (PA) systolic pressure (in the absence of RV or pulmonary valve (PV)/PA obstruction) is to place the continuous- wave (CW) Doppler cursor through the TR flow acceleration as it
Because of the complex nature of the TV, and the difficulty in see-
clearly identifies the TV orifice through which TR occurs. The size
ing all 3 leaflets in a single 2D plane, a comprehensive assessment
and variability of the inferior vena cava (IVC) should govern the as-
of the TV using B-mode (in some cases M-mode also) and conven-
sessment of RA filling pressures, relative to respiratory phase. It is
tional and color Doppler should be performed using all transtho-
also important to assess RV function either visually or using other
racic windows and planes in which the TV is visualized.35 Usually,
techniques such as RV fractional shortening, tricuspid annular plane
the AL and PL are visualized in most planes, but the PL(IL) may be
systolic excursion (TAPSE), and 3D echocardiography in all patients with TV pathologies. Other valves and cardiac structures should also be examined for any associated pathologies which may need to be taken into account when considering TV procedures.36 Currently, TR is diagnosed by 2DTTE by noting reversed color Doppler flow signals moving from the RV into the RA during systole with severity being semiquantitatively estimated by comparison of the size of the maximal regurgitant jet (RJ) area in relation to area of the RA taken in the same frame, showing largest area of regurgitation, with multiple examining planes being assessed for the largest jet keeping the Nyquist limit or aliasing velocity between 50 and 60 cm/s and optimizing color gain appropriately.38 This standardization of the Nyquist limit and color Doppler gain is very important in estimating TR severity but has not been emphasized enough in the current guidelines. In most equipment, changes in Nyquist limit also simultaneously result in changes in the color filter such that a low Nyquist limit will magnify the TR jet size and a high Nyquist limit will result in jet size reduction thus resulting in
F I G U R E 3 Schematic of the aortic short-axis view showing tricuspid, aortic, and pulmonary valves. LAA = left atrial appendage; PA = pulmonary artery; PV = pulmonary valve. Other abbreviations are as in previous figures. Reproduced with permission from Nanda NC. Atlas of Color Doppler Echocardiography. Philadelphia: Lea and Febiger; 1989:194
an erroneous estimation of TR severity. When these criteria were initially developed by our group in the 1980s for both TR and MR, we had set the Nyquist limit between 40 and 50 cm/s but, with technical improvements in echo equipment that have occurred over the years, it seems more prudent to keep the Nyquist limit between 50 and 60 cm/s. Color gain is another important factor that needs to be
F I G U R E 4 Reconstruction of the tricuspid valve annulus from live/real time three-dimensional transesophageal images using a software meant for reconstructing the mitral annulus. A = anterior; AL = anterolateral; P = posterior; PM = posteromedial. Other abbreviations are as in previous figures
Faint/Partial or parabolic 34%
20%–34% 5–10
Usually present
None
Maximum TR jet area/RA area in the same frame by TTE2 (commonly used parameter)
None
E-wave >1.0 m/s
Extension of TR jet into coronary sinus
Variable Systolic flow reversal
A-wave dominant
Hepatic vein (vertical) flow
Tricuspid inflow
2.5
Normal
IVC diameter (cm)1 2.1–2.5
Mostly dilated (RV, apical 4-chamber view, at the base >42 mm, midlevel >35 mm, longitudinal dimension >86 mm, RA area >18 cm², RA major dimension >53 mm, and minor dimension >44 mm)
Normal or mild dilatation
Mostly normal
Severe
RV and RA size1
Moderate Systolic noncoaptation of TV and visualization of chordae prolapsing into RA
Mild
Tricuspid valve morphology
TR severity
TA B L E 3 Assessment of tricuspid regurgitation severity by echocardiography
MURRAY et al. 1423
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et al39 also found that a large TVA measuring 38 mm or more in maximum diameter in diastole correlated with severe TR, using intraoperative saline infusion in the right ventricle as a reference standard. A prominent flow acceleration and a large vena contracta (VC) width measuring >0.7 cm by 2DTTE color Doppler are also useful signs of significant TR; also, a TR jet extending into a hepatic vein (HV) producing reversed flow in systole usually indicates severe TR, in which case it may also extend into the CS. It should be noted that, with both eccentric or very severe TR, the TR jet may be altered; in the former, a marked reduction in the velocity of blood cells due to the impact of the TR jet with the adjoining leaflet or RA wall immediately after exit from the TV may cause a loss of the mosaic pattern of colors indicative of high velocity and turbulence, known as the Coanda effect, which results in the conversion of the high-velocity turbulent signals into laminar flow signals; in the latter, if there is deficient leaflet tissue, this results in a virtual equilibration of RV and RA pressure, nullifying the turbulence and again F I G U R E 5 Schematic of apical four-chamber view showing the Doppler color flow management technique. Right atrial area (RAA) taken in the same plane in which the maximal regurgitant jet area (RJA) is observed. RAA = right atrial area; RJA = maximal regurgitant jet area. Other abbreviations are as in previous figures. Reproduced with permission from Nanda NC (Ed) Comprehensive Textbook of Echocardiography, New Delhi, India, Jaypee Brothers Medical Publishers, 2014
creating laminar flow signals; and these 2 phenomena may cause TR to be completely missed or misdiagnosed, since one is used to looking at turbulent flow signals and not laminar as evidence of regurgitation, possibly leading to an underestimation of TR severity. In cases of eccentric TR, it is important to consider the laminar blue/red signals which move with the turbulent flow signals since they also represent part of regurgitation, and if this is done, that is, the area of laminar flow signals is added to the area of turbulent flow signals, there is less chance of missing severe TR. When checking for TR severity, one
taken into consideration as stated above. A very low color gain can
should also pay attention to color M-mode and CW Doppler, which
virtually wipe out any trace of TR even when it is severe, and a very
will show whether TR is pansystolic or occurs only during mid-to-late
high gain will magnify the TR jet which could result in the misdiag-
systole as in patients with TV prolapse. Thus, what may appear to
nosis of mild or moderate TR as severe TR. The best way to stan-
be severe TR by color Doppler jet area may be only moderate if TR
dardize color Doppler gain is to increase it till stationary artifactual
is confined to mid-or late systole. In these cases, the VC could be
echoes or random color speckle from nonmoving structures appear
large and misleading but TR volume would be low. Both 2DTTE and
with the TR signals often appearing to cross the RA borders; then,
Doppler color flow mapping are useful in identifying patients who
the color gain is reduced slowly till these artifacts just disappear and
would require TV repair for severe tricuspid regurgitation.39
this particular gain level is used for severity estimation. This needs
2DTEE imaging modality may facilitate visualization of the TV
to be done at every follow-up visit and sometimes during the same
because of the proximity of the transducer which is inserted into
study when changing examination planes. Since TR severity cannot
the esophagus. This is especially useful in patients with poor trans-
be estimated reliably by angiography where the catheter needs to
thoracic windows and those undergoing surgical or percutaneous
pass through the TV for contrast injection into the RV potentially
TV procedures in whom TTE is not practical.40 All 2DTEE views in
resulting in varying degrees of TR by the presence of the catheter it-
which the TV is visualized should be used, and the TV and other
self in the TV orifice, Chopra et al39 studied patients who underwent
cardiac structures should be studied comprehensively as described
or did not undergo TV repair or valve replacement based on a com-
for 2DTTE36 (Table 3, Figures 5–15).
bination of clinical and operative findings at surgery and correlated that with color Doppler examination. They found that, in all patients who underwent TV surgery, the maximum TR jet occupied 34% or more of the RA and the jet was smaller in those in whom the surgeon
5 | TH R E E- D I M E N S I O N A L I M AG I N G O F TH E TR I CU S PI D VA LV E
decided not to operate on the TV. Thus, a TR jet occupying 34% or more of the RA by color Doppler is consistent with severe TR, while
The development of various modalities of echocardiography contin-
smaller jets mean less severe TR. If the RA is very large in size, the
ues to evolve, initially with M-mode then 2D imaging and now 3D
color Doppler jet in severe TR may not occupy more than one-third
imaging; it must be noted that 2DTTE has probably had the largest
of its size and this factor should be considered when estimating TR
individual impact on the method of imaging for evaluation of car-
severity. Conversely, mild TR may fill a substantial portion of a small
diac disease; and guidelines governing diagnosis and management of
RA resulting in overestimation of TR severity. Interestingly, Chopra
heart disease in general have arisen from this method. However, the
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(A)
(B)
(C)
(D)
(E)
(F)
F I G U R E 6 Effect of Nyquist limit and color gain on color Doppler regurgitant jet area. Two-dimensional transthoracic echocardiography. A–F, Apical four-chamber views showing mitral (MR) and tricuspid (TR) regurgitation. A low Nyquist limit (30 cm/s in [A]) or high color gain (100% in [F]) results in color Doppler signals not only filling up the entire atrium but also extending beyond the cardiac borders. This will lead to overestimation of regurgitation severity. On the contrary, a high Nyquist limit (80 cm/s in [C]) or low color gain (30% in [D]) causes a marked reduction in the size of the regurgitant jet leading to underestimation of regurgitation severity. The Nyquist limit was standardized between 40 and 50 cm/s in (B) and (E), and this range (currently suggested between 50 and 60 cm/s) should ideally be used when utilizing the jet area to atrial area ratio method for estimating regurgitation severity. The Nyquist limit per se does not change the jet area, but the wall filter which also changes when the Nyquist limit is changed on ultrasound machines has a profound effect on the size of the regurgitant jet and other flow signals. Changes in wall filter settings essentially determine the extent of elimination of lower velocity flow signals from the regurgitant jet. Movie S1A,B. Abbreviations are as in previous figures. Reproduced with permission from Nanda NC (Ed) Comprehensive Textbook of Echocardiography, New Delhi, India, Jaypee Brothers Medical Publishers, 2014
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(A)
(B)
(C)
F I G U R E 7 Effect of color gain on tricuspid regurgitation severity. Two-dimensional transthoracic echocardiography. A, Color flow (CF) gain has been turned very high (86%) resulting in artifactual color Doppler echoes not only filling the complete extent of the right atrium (RA) but also extending beyond the RA border. B, Color gain was gradually reduced till the artifactual echoes just disappeared. This is the optimal setting, and TR is noted to be severe. The arrow points to swirling of TR in the RA with the flow signals moving toward the TV. C, Color gain has been turned way down to 48% resulting in loss of most of TR signals. This could be erroneously interpreted as minimal TR. Movie S2A,B,C. F = flow acceleration. Other abbreviations are as in previous figures main limitation of 2DTTE is that at any given time it provides only a
plane angulation. En face views of the TV, not usually possible by
thin slice of cardiac structures such as the TV, precluding compre-
2DTTE, are easily obtained by 3D imaging. In modern equipment,
hensive assessment. On the other hand, a much larger section of
the same transducer that is used for 2D imaging can now be used for
the heart is acquired when using 3DTTE or 3DTEE. In the case of the TV, all the leaflets in their entirety, the subvalvar structures, as well as other surrounding structures are captured in the 3D datasets
• TR is diagnosed by systolic Doppler color flow signal rever-
and these can be cropped or sectioned and viewed using any desired
sal from RV to RA with severity estimated by comparison of maximal RJ area to RA area in the same frame.
• There is difficulty seeing all leaflets of the TV from a single 2D plane, warranting multiple views. Even then, the leaflets may be misidentified. • The planes for visualization of the TV are mitral and aortic short-axis, apical four-chamber, RV inflow, RV apical twochamber, subcostal four-chamber, RV inflow–apical outflow, and right parasternal views. • B-mode examinations are to be supplemented by color Doppler to assess abnormal flow patterns.
• The Nyquist limit must be kept between 50 and 60 cm/s with color gain appropriately adjusted. • In eccentric or severe TR, the Coanda effect and laminar flow signals must be considered. • 2DTEE facilitates a close and accurate visualization of several important valvular structures. • The major limitation with 2DTTE is with the need to mentally reconstruct a 3D picture from multiple 2D planes and the inability to simultaneously visualize all leaflets in most cases.
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3D imaging obviating the need for a different transducer and is thus a valuable time saver. The same imaging planes that are used for 2D imaging can be used for acquisition of 3D data sets. Tricuspid valve anatomy, anatomic relationship, and physiology as regards leaflet movement and coaptation are made easier, given that 3DTTE allows en face views of the short axis of the TV from both the atrial and the ventricular aspects, and this allows for a comprehensive evaluation of all three leaflets; this was previously difficult to view in 2D planes; and other subvalvular structures such as the chordae tendineae, papillary muscles, as well as the moderator band can be seen with clearer delineation as well.41 Of particular importance is that now the PL can be simultaneously visualized. It should be noted that a more accurate assessment of the TV orifice area in patients with TV stenosis, along with carcinoid disease, can also now be obtained.42,43 Other structural defects can also now be adequately identified, leading to mechanisms of TR being easily elucidated.44,45 Color Doppler 3DTTE also allows for quantitative assessment of severity of TR without the previous challenges presented with 2DTTE. One of the major advantages of 3DTTE over 2D imaging is the ability to reliably assess the shape and size of the TR VC, through which regurgitation can be visualized going into the RA. The product of the VC size and velocity time integral of the TR jet obtained by CW Doppler interrogation gives the volume of regurgitation, and this provides a quantitative estimate of TV regurgitation severity and is potentially helpful in clinical decision-making and planning of further definitive treatment, particularly regarding the timing of surgery as well as follow-up. From this standpoint, 3DTTE is superior to 2DTTE which is a slice technique providing one or two dimensions of the VC and therefore failing to assess its exact size and shape.46 Also, 3DTTE obviates the need to make mostly incorrect assumptions regarding the shape of the flow
F I G U R E 9 Severe tricuspid regurgitation. Two-dimensional echocardiography. Subcostal view showing flow signals (red) moving into a vertical hepatic vein (HV, arrow) during systole. Inferior vena cava (IVC) is markedly dilated. Movie S4. HV = hepatic vein; IVC = inferior vena cava; L = liver. Other abbreviations are as in previous figures acceleration or proximal isovelocity surface area (PISA), which when using 2DTTE/Doppler is often done to indirectly derive the effective orifice area. This makes 3DTTE not only more accurate but also simpler to use than 2DTTE in quantitative assessment of the severity of TR. Visualization of the TV leaflets en face in B-m ode in the short axis using 3DTTE also provides the assessment of the exact size, shape, and size of TV leaflet defects, which may be congenital 47 or acquired as is the case in endocarditis,48–51 which may also result in loss of leaflet tissue. In patients with a dilated TVA or RV, the size of the TV leaflet area which does not coapt and the extent of tethering and displacement of TV leaflets into the RV may also be evaluated. Although 3DTTE full-volume acquisition mode is able to accommodate many heart structures within a single 3D dataset, this often requires enlargement of the volume angle too, which reduces the
F I G U R E 8 Severe tricuspid regurgitation. Two-dimensional transthoracic echocardiography. The arrows point to laminar red nonturbulent color flow signals moving toward the TV. In Movie S3, these are seen moving in the phase as the mosaic-colored turbulent TR signals and represent part of TR. These nonturbulent, laminar signals should be added to mosaic turbulent signals when assessing TR jet area. F = flow acceleration. Other abbreviations are as in previous figures
F I G U R E 1 0 Severe tricuspid regurgitation. Two-dimensional transthoracic echocardiography. The arrow points to eccentric TR signals moving into the coronary sinus (CS) during systole. Movie S5. Other abbreviations are as in previous figures
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frame rate and therefore temporal resolution. Hence, the guidelines
procedures involving the TV. The same views that are used for
recommend that 3D datasets be acquired from multiple transtho-
2DTEE can be used for 3D acquisition.
racic transducer positions, with focused and complete examinations
When displaying the TV en face, it is recommended that the SL
being the two options; the former consists of only a few 3D datasets
should be located at 6 o’clock position. Full-volume datasets should
being used to complement a complete 2D study. The focused exam-
be optimized to view both the TV and the RV; once pertinent struc-
ination is commenced with 2D and then switched to live/real time
tures are within the cropping plane, the image can be optimized by ad-
3D to see whether the 2D structure is encompassed in volume of
justment of gain, compression, and magnification. Cropping using the
interest, then full-volume or zoom mode is applied. The zoom mode
multiplanar mode is useful to make accurate measurements since each
focuses on a relatively small area of interest such as the TV with-
plane is a two-dimensional section derived from the 3D dataset.41
out details of surroundings but does so at an increased frame rate
New tricuspid interventions are expected to increasingly
with enhanced resolution. A complete 3DTTE examination requires
rely on 3DTEE or 3DTTE for guidance during the procedure. 52,53
multiple acquisitions from the left parasternal, apical, subcostal, and
Catheter-based interventions continue to expand, and this modal-
right parasternal transducer positions.
ity is becoming increasingly necessary in preprocedural planning,
3DTEE imaging of the TV is useful in those with poor transtho-
intraprocedural guidance, and postprocedural assessment; the main
racic acoustic windows and also during surgery and percutaneous
specific benefits are the ability to visualize the valve undergoing
(A)
(B)
(C)
F I G U R E 1 1 Two-dimensional transthoracic echocardiography in tricuspid valve prolapse with mid-to-late systolic regurgitation. A, Apical four-chamber view. Arrow points to tricuspid regurgitation jet moving from right ventricle (RV) into the right atrium (RA). Tricuspid valve (TV), left atrium (LA), mitral valve (MV), and left ventricle (LV) are also seen. B, Color Doppler-guided continuous-wave Doppler. Arrowhead points to a mid-to-late tricuspid regurgitation jet velocity waveform. C, Color M-Mode. Arrowhead points to tricuspid regurgitation jet confined to mid-to-late systole. C points to tricuspid valve closure. Movie S6. Abbreviations are as in previous figures. Reproduced with permission from Elsayed M, Thind M, Nanda NC. Two-and three-dimensional transthoracic echocardiographic assessment of tricuspid valve prolapse with mid-to-late systolic tricuspid regurgitation Echocardiography. 2015 Jun;32(6):1022–5. https://doi.org/10.1111/echo.12954
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with ICE for paravalvular leak closure in particular has been reported to be feasible and advantageous55,56 with a reduction in the use of contrast reported when 2D ICE is used in transcatheter aortic valve replacement (TAVR).57,58 Larger field-of-view transducers and recent incorporation of 3D imaging may further enhance the utility of this modality and may make this technique a suitable alternative for patients with TR in whom other imaging modalities present a challenge for various reasons.
7 | TR A N S C ATH E TE R A PPROAC H E S TO TR With the high surgical risk of reoperation, coupled with a growing number of patients with transcatheter (TC) left-sided heart devices, F I G U R E 1 2 Severe tricuspid regurgitation. Two-dimensional transthoracic echocardiography. Right ventricular inflow view. Severe functional TR is noted in this patient with poor right ventricular (RV) function. The tricuspid valve leaflets do not coapt (arrow) in systole and are displaced into the RV. Movie S7. Abbreviations are as in previous figures
there is a vigorous developmental thrust into TC solutions for FTR. There must be the consideration of several challenges specific to this
• Despite clear advantages of 3DTTE over 2DTTE as regards VC measurement of the TR jet and the obviation of the need to make geometric assumptions, temporal resolution is rela-
interventional treatment en face in real time or full-volume mode,
tively low, but this may be less of a problem with current ad-
which is impossible with other types of imaging, as well as a real
vances in 3D technology. 3DTTE has been shown to improve
time view of the instruments secured. It is also helpful with accu-
sizing of TC valves, with 3DTEE comparable to computerized
rate sizing of the valve, as well as the production of accurate annular
tomography (CT) for annular assessment and having the ca-
measurements.54 This constantly developing tool will improve the
pability to optimize percutaneous procedural performance.
accuracy and effectiveness of TV interventions as its utilization con-
• 3DTEE will also be useful in postprocedural assessment of
tinues to expand (Figures 16–25).
the treated TR. • ICE has value in guidance of percutaneous procedures as
6 | I NTR AC A R D I AC EC H O C A R D I O G R A PH Y
well as in diagnosis primarily in cases where other imaging modalities pose a challenge.
With the current move toward conscious sedation, in the case of interventions for structural heart disease, intracardiac echocardiography (ICE) may be a viable alternative in some patients with no other adequate intraprocedural imaging options. The advantages are similar to TEE except the probe can be positioned close to an intracardiac structure of interest, and it may provide a different perspective as the imaging planes obtained are often different from TEE. Imaging • 3DTTE represents a novel modality that improves the accuracy of structural imaging, particularly leaflet movement and coaptation. • Leaflet visualization is also more comprehensive given that en face views of all three leaflets are now possible. • It is now easier to elucidate pathophysiology of TV disease with 3DTTE. • 3DTTE color Doppler now allows for assessment of TR jets that are no longer in planar view as is the case with 2DTTE. • It is recommended that 3DTTE datasets be taken from multiple transducer positions, in the format of either a focused or complete examination.
F I G U R E 1 3 Tricuspid valve prolapse. Two-dimensional transesophageal echocardiography. Shows marked prolapse of individual segments of the tricuspid valve (ATV) with thickening (arrowheads) consistent with myxomatous degeneration. Reproduced with permission from Nanda NC, Domanski MJ. Atlas of Transesophageal Echocardiography. 2nd ed. Philadelphia: Lippincott Williams & Wilkins; 2007:195
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(A)
F I G U R E 1 4 Severe tricuspid regurgitation. Two-dimensional transesophageal echocardiography. A large regurgitant jet is seen indicative of severe TR. A relatively small zone of flow acceleration (arrow) is seen even though the patient has torrential TR, almost completely filling the massively dilated right atrium. Abbreviations are as in previous figures. Reproduced with permission from Nanda NC (Ed) Comprehensive Textbook of Echocardiography, New Delhi, India, Jaypee Brothers Medical Publishers, 2014
(B)
approach, including severe dilatation and noncircular shape of the TVA, thin or nonuniform annular tissue, particularly for the SL; angle of catheter approach, superior vena cava (SVC) or inferior vena cava (IVC) approach, noncompacted or small RV chamber with papillary muscles and moderator band, thin RV free wall, and right coronary artery (RCA) proximity to the annulus. The main TC devices showing promise or currently in trials which best address severe TR warranting interventional treatment are the MitraClip®, the Forma Spacer®, the Trialign® system, and caval devices, as well as some additional implements still currently under study, and we will look at them in more detail here. The MitraClip® (Abbott Vascular, Santa Clara, CA, USA) has in recent times been found to successfully treat TR. It grasps and brings together edges of opposing TV leaflet segments. It has been placed using a transjugular procedure, guided by TEE utilizing an SVC (A)
F I G U R E 1 6 Three leaflets of the tricuspid valve. Live/real time three-d imensional transthoracic echocardiography. A,B, En face views in two different patients showing all three TV leaflets in the open position. Movie S9. A = anterior leaflet; P = posterior leaflet; S = septal leaflet. Other abbreviations are as in previous figures. Reproduced with permission from Pothineni et al 41
(B)
F I G U R E 1 5 Two-dimensional transesophageal echocardiography. A, The Nyquist limit has been reduced to 20 cm/s resulting in TR signals filling the RA completely. B, The Nyquist limit has been increased to 46 cm/s resulting in incomplete filling of RA. Movie S8A,B. Abbreviations are as in previous figures
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(A)
(B)
(C)
(D)
F I G U R E 17 Live/real time three-dimensional transthoracic echocardiography. Rheumatic tricuspid valve stenosis/tricuspid valve regurgitation. A, The arrow points to the tricuspid orifice in a patient with TV stenosis. The orifice area measured 2.02 cm2 in diastole. B,C, En face views in another patient with mild TV stenosis but severe TR. The tricuspid orifice area (B) measured 2.4 cm2 in diastole. Systolic frame (C) shows noncoaptation of TV leaflets in the same patient as (B). This measured 0.4 cm2 in area and resulted in severe TR as assessed by two-dimensional color Doppler. D, En face view from the ventricular aspect in a third patient with rheumatic heart disease showing systolic noncoaptation (arrow) of the TV. Movie S10A,BC,D. Abbreviations are as in previous figures. Reproduced with permission from Pothineni K et al41 approach; of importance is the alignment of the plane of the annulus
good results so far; this involves the transjugularly approached echo-
as perpendicular to the TEE beam as possible; and this technique in-
cardiographically guided placement of pledgeted sutures within the
traprocedurally makes the most use of the low esophageal views for
posterior annulus of the TV, spanning the length of the PL, utilizing
assessing the TR jet and imaging the actual grasping of the leaflets,
a dedicated plication lock device, and the bringing together of the
with Doppler deep transgastric views being used to postprocedurally
pledgeted sutures; midesophageal or transgastric TEE views are used
confirm clip position. This has led to recipients of the device witness-
to visualize the wire crossing the TV annulus, with good mid-and long-
ing a decline in the severity of their TR by at least one grade, but it is
term results seen so far, with an acute reduction in annular orifice and,
not without complications, such as clip detachment, chordal device
consequently, TR seen. Its main drawback is the technical complexity
entanglement, or TV stenosis, as well as the fact that the three leaf-
and challenge, as well as the risk of RCA damage1,20 (Figure 26).
1,20
lets possess different tissue properties.
Caval valve TC implantation techniques have demonstrated ex-
The Forma® (Edwards Lifesciences Corporation, Irvine, CA, USA)
perimental promise when in the IVC alone or in both the IVC and
spacing device utilizes a left subclavian vein approach that essentially
SVC, primarily with the effect of IVC pressure reduction; its initial
anchors a foam-filled device to the RV apex, against which the regurgi-
success in the form of normalization of liver function and continued
tant TV leaflets can coapt. This device comes in three sizes, the choice
improvement in mean caval pressures has eventually given way to
of which is contingent on the largest VC width. In the preparation for
the HOVER Trial, which is testing the Edwards-Sapien XT transcath-
this procedure, the complex and unique dimensional knowledge of the
eter valve (Edwards Lifesciences Corporation) in the IVC for treat-
TV is ensured by obtaining a CT to clarify this complex anatomy; the
ment of severe TR where an open surgical approach is not feasible;
actual placement relies on fluoroscopic, 2D and 3DTEE guidance in
this, like the Forma spacing device, requires CT imaging of the IVC
guiding balloon tip to anchoring position as well as confirming path
prior to placement, and this study is currently enrolling patients.1,20
of device, and anchor deployment and positioning; again 2D/3DTEE
Tricuspid valve-in-valve implantation (TVIV) procedures consti-
can be used to review the final positioning and VC area of any residual
tute a novel and evolving approach to the treatment of dysfunctional
jets; success has been seen with this device as well with at least one
surgical TV bioprostheses, harnessing the off-label use of both aortic
acute grade reduction in TR severity; and the main drawback with this
and pulmonary valve prosthetic devices. A multicenter study involv-
device is with patients in whom the TR orifice is very large, warranting
ing 156 patients from 53 centers involved the implantation of one
1,20
of two devices; the Melody valve (Medtronic Inc, Minneapolis, MN,
The Trialign® Mitralign, Inc. (Tewksbury, MA, USA) system is sim-
USA), which was generally placed in the younger patients more likely
ilar to the modified Kay bicuspidization procedure, with generally
to have congenital heart disease, requiring smaller surgical devices,
a very large device to counter the obvious lack of leaflet coaptation.
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performed saw technical success and resulted in improved TV function and substantial improvement of symptoms, with substantial mortality being concentrated among those patients who were in poor preprocedural condition. The 71% of patients with pre-T VIV NYHA class of III to IV was reduced to 14% at follow-up. It was interesting to note that outcomes did not differ significantly regarding TVIV valve type either.59 There are a number of other devices that are currently under investigation or in trials, namely the TriCinch® Transcatheter Device (4Tech Cardio, Galway, Ireland) system, which involves the implantation of tethering device to reduce the anteroposterior dimension of the annulus and consequent improvement in coaptation; the Millipede® system (Millipede LLC, Ann Arbor, MI, USA), an imF I G U R E 1 8 Live/real time three-dimensional transthoracic echocardiography. Carcinoid heart disease. Arrow points to the restricted TV orifice viewed in short-axis view in a patient with carcinoid heart disease. Movie S11. Abbreviations are as in previous figures. Reproduced with permission from Pothineni et al41
plantable ring placed on the atrial side of the TVA, to restore shape and diameter; and the transatrial intrapericardial tricuspid annuloplasty, or TRAIPTA concept, which essentially is a circumferential implant which exerts compressive force over the annulus, is placed along the atrioventricular groove in the pericardial space, having gained pericardial access, then tension is to be applied, modifying
and tended to employ intraprocedural ICE during placement, and the
TVA geometry, reducing TR. Echocardiographic imaging of the TV
Sapien (Edwards Lifesciences) which was implanted in both small and
plays an essential role in quantifying TR and chamber size and func-
larger bioprostheses equally, and tended to employ TEE during valve-
tion, as well as guiding the procedures. Because the TV is close to
in-valve placement; this study involved the collection of a number of
the chest wall, a better anatomic characterization of the TV may be
critical procedural variables, including valve type and size; vascular ac-
seen in TTE imaging in some patients than TEE imaging.
cess used for implantation; use and method of intraprocedural echo-
Via TEE, however, the multiple windows afforded by the proximity
cardiography; use, site, and method of rapid pacing applied during
of the TV to the esophagus and the gastric fundus provides the imager
the procedure; predilation or prestenting of the surgical valve prior
with many options to image the entire tricuspid apparatus using both
to TVIV; postdilation procedure of the valve after implantation; pro-
2D and 3D modalities. Whereas TC interventions on the TV could
cedural success; and adverse events. The vast majority of procedures
be performed using TTE, there are many advantages to using TEE to
(A)
(B)
(C)
F I G U R E 1 9 Live/real time three-dimensional transthoracic echocardiography. Tricuspid valve prolapse. A, En face view from atrial aspect showing systolic prolapse of S1, S2, A2, A3, P1, and P2 TV segments. B, En face view in another patient showing prominent systolic prolapse of A1, A2, A3, S2, and S3 TV segments. Mild prolapse of P2 segment of the TV is also noted. C, Schematic shows proposed division of all three TV leaflets into three equal segments numbered 1, 2, and 3. Movie S12. AV = aortic valve. Abbreviations are as in previous figures. Reproduced with permission from Pothineni et al41
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• TC TR treatments are novel and rapidly developing, primarily driven by the mortality benefits of a minimally invasive approach to addressing TR. • Considerable technical difficulty may be encountered given the existing structural variability of the TV. • The main devices currently employed are the MitraClip in TV position, Forma Spacer, Trialign system, and Caval devices. • TVIV procedures are available for addressing dysfunctional surgical TV bioprostheses. • These devices all require multiple modalities of echocardiography for pre-, intra-, and postprocedural imaging of valvular structures, pathophysiology, and prospective landing zones.
(B)
oval-shaped,65 and becomes more circular and planar66 with annular dilation. Due to the complexity of the TV anatomy and the investigational nature of the TC TV therapies, 3D printing can be helpful in the procedural planning.67 While most commonly based on data from 4-dimensional (4D) cardiac CT data, 3D printing can also be performed based on 3DTTE and/or 3DTEE views (Figure 27).
8.1 | Building the model for printing Using a 3D modeling and reconstruction software, the right-sided anatomy, including the TV leaflets, can be modeled based on good quality 3D data from echocardiography. Different material with variable properties can be incorporated to highlight differences in tissue F I G U R E 2 0 Live/real time three-dimensional transthoracic echocardiography. Flail tricuspid valve. A,B, Arrows point to the site of chordae rupture to the anterior TV leaflet visualized in apical four-chamber (A) and short-axis(B) views. Movie S13A,B. Abbreviations are as in previous figures. Reproduced with permission from Pothineni et al41 guide these procedures; there is now the ability to continuously image without procedural interruption to confirm catheter or wire position; equally important is the reduction in radiation exposure to the imager. Intraprocedural imaging of the TV will be further enabled by standard-
composition; for example, more rigid material can be used to mimic calcifications, while the leaflets can be printed with a softer material. The printed model allows: • Detailed analysis of the patient’s right-sided anatomy: While 3D imaging modalities acquire images in 3 dimensions, these are projected on a 2D screen, limiting accurate representation of the spatial relationships. • Procedural planning: including measurements of the distance and angulation between the catheter entry site and the TVA (delivery
ization of the image display and automation of image orientation by the development of the pertinent software (Table 4). • The best candidates for 3D printing are patients undergoing
8 | TH R E E- D I M E N S I O N A L PR I NTI N G I N TH E PRO C E D U R A L PL A N N I N G O F TR A N S C ATH E TE R T V I NTE RV E NTI O N S
innovative procedures or those with challenging anatomy, where simulation of the procedure prior to the actual one could be useful. • To be able to create a good quality 3D model, a good quality 3D dataset showing optimally all the structures of interest
3D printing holds revolutionary potential. Patient-specific anatomic de-
is required.
tails can be produced and manipulated, and personalized interventions
• If imaging is suboptimal, 3D printing will be suboptimal/
can be planned and tested.60,61 Although currently not translated into
nonfeasible, and this may be seen as an instance where 3D
clinical practice, there is rising interest in its implantation into the clinical arena. Significant anatomic challenges arise when considering TC therapies for the TV.62 It is the largest valve, with a complex anatomy that varies considerably.63,64 In healthy subjects, the TVA is nonplanar,
printing may not be a viable option. • There is no sensitivity data yet on 3D printing as it is a new and emerging technology.
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(A)
(B)
(C)
(D)
(E)
F I G U R E 2 1 Live/real time three-dimensional transthoracic echocardiography. Right ventricular papillary muscle rupture. A–C, The arrowhead points to the ruptured muscle which prolapses into the right atrium in diastole. D,E, Color Doppler examination shows a large flow acceleration (FA, arrow in [D]) as well as a large vena contracta (arrow in [E]) viewed en face and measuring 1.0 cm2 in area indicative of very severe TR. The arrowhead in D points to the prolapsing papillary muscle. Movie S14. Abbreviations are as in previous figures. Reproduced with permission from Pothineni et al41
(A)
(B)
F I G U R E 2 2 Live/real time three-dimensional transthoracic echocardiography. Tricuspid valve endocarditis. A, Arrow points to a vegetation on the TV viewed in short axis. No echolucencies were noted on sectioning the vegetation suggesting there was no abscess formation. B, Arrow shows a large abscess at the junction of the TV and aorta in another patient. Abbreviations are as in previous figures. Reproduced with permission from Pothineni K et al41
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F I G U R E 2 3 Live/real time three-dimensional transthoracic echocardiography. Tricuspid valve fibroelastoma. Arrow points to an irregular mass with fronds attached with a stalk to the septal leaflet (S) of the TV. Movie S15. Abbreviations are as in previous figures. Reproduced with permission from Nanda NC (Ed) Comprehensive Textbook of Echocardiography, New Delhi, India, Jaypee Brothers Medical Publishers, 2014
F I G U R E 2 5 Live/real time three-dimensional transthoracic echocardiography. Ebstein anomaly. The arrowhead shows a bubble-like appearance resulting from intermittent tethering of the septal leaflet of the TV to the ventricular septum. Movie S17A,B. Abbreviations are as in previous figures. Reproduced with permission from Pothineni et al41
site), allowing accurate estimation of the amount and degree of
a proper assessment of individual dimensions is better facilitated
steering needed to deliver the device.
when multiple echocardiographic modalities are appropriately de-
• Appropriate sizing of the prosthesis based on direct assessment
ployed. Also, and very importantly, intraprocedural imaging for TC
• Practicing valve delivery and deployment on the model.
solutions for FTR is critical to effectiveness and long-term success of the chosen procedure, and the above-mentioned techniques play a vital role in guaranteeing same. This literature review has sought
9 | CO N C LU S I O N
to draw on the most current and novel approaches to assessment of the TV with special reference to FTR, with the prospect of a mini-
Interest in the TV has increased and continues to do so, in the knowl-
mally invasive corrective procedure of same; this will hopefully en-
edge that FTR impacts morbidity and mortality in a significant way.
gender the best possible outcome for each patient who is deemed
The anatomy and function of this valve are remarkably complex, and
to have candidacy.
(A)
F I G U R E 2 4 Live/real time three-dimensional transthoracic echocardiography. Tricuspid valve prosthesis. A, B. Normal bioprosthetic TV leaflets (arrow) seen in open (A) and closed (B) positions. Numbers 1, 2, and 3 represent the three struts of the prosthetic valve. C, The arrow shows systolic noncoaptation of the leaflets in another patient with a bioprosthesis. Movie S16. Abbreviations are as in previous figures. Reproduced with permission from Pothineni K et al41
(B)
(C)
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F I G U R E 2 7 A–E, Figure: Panels A and B: Three-dimensional transthoracic and transesophageal echocardiographic data can be used to generate three-dimensional printed right-sided models (C: side view; D: atrial view). These models can be used for procedural simulation (E). Contributed by Serge Harb, MD, Cleveland Clinic, Ohio F I G U R E 2 6 Trialign System (Mitralign) TA B L E 4 Transcatheter devices used to reduce tricuspid regurgitation severity Prior considerations
Procedural considerations
Important imaging views
Leaflet clipping Transcatheter edge-to-edge delivery of clip which grasps and approximates edges of opposing TV leaflet segments
Leaflet involved, the presence/ absence of coaptation gap, and approachability Leaflet length as regards graspability
Greatest cardiac output obtained with septal–anterior and septal–posterior leaflet tip clips Best result may be obtained with septal-anterior coaptation using multiclip approach
Views of midesophageal and deep esophageal or GE junction yield best imaging for leaflet grasp and 3D reconstruction for clip positioning Avoid views with acoustic shadowing of leaflet tips 3D color Doppler will assess residual TR
Forma spacing device Implantation of an anchor attached to a foam-filled spacer device which creates a coaptation surface for regurgitant TV leaflets
Estimation of TV EROA important Baseline EOA and risk of obstruction with device Ideal anchor path in RV Consideration of large papillary muscles, moderator band, and trabeculations
If leaflets thickened and nonpliable or isolated commissural jets present, then closure around device will not be permitted. Optimal leaflet coaptation around device may be impeded by PPMs.
Transgastric views with 3D for reconstruction of the RV anchor path and landing zone Midesophageal simultaneous biplane views centered on the regurgitant jet to optimize device position for TR reduction 3D color Doppler to assess TR pre-and postplacement
Trialign device Bicuspidization of TV by placement of pledgeted sutures within TV annulus spanning length of posterior leaflet and using a dedicated plication lock device to bring sutures together
Important to assess as pure FTR Consider whether valvular bicuspidization will adequately reduce TR Adequacy of a minimally 2–4 mm annular shelf Number of pledgeted sutures needed Location of RCA in relation to annulus
Degenerative TR may not benefit from annular reduction, hence need for adequate preassessment Pacemakers causing tethering of the leaflet tips may not benefit from annular reduction
Mid-and deep esophageal 2D views of the wire depth of annular crossing Transgastric views may be used 3D reconstruction for measurement of annulus, EOA, and EROA pre-and postplacement
Caval devices Transcatheter placement of a lone valve into IVC or a second in SVC, to treat upstream effect of severe TR
Assessment as to whether symptoms are primarily congestive hepatopathy IVC size must be appropriate for stent and transcatheter valve Need for adequate distance between RA and hepatic veins to fit the transcatheter valve
Largest IVC stent currently available is 30 mm Avoid obstruction of the hepatic vein
Mid-and deep esophageal 2D views of the IVC-R A junction Shallow transgastric views of the IVC and hepatic vein
2D = two-dimensional; 3D = three-dimensional; EOA = effective orifice area; EROA = effective regurgitant orifice area; FTR = functional tricuspid regurgitation; GE = gastroesophageal; IVC = inferior vena cava; PPM = posterior papillary muscle; RA = right atrium; RCA= right coronary artery; RV = right ventricle; SVC = superior vena cava; TV = tricuspid valve; TR = tricuspid regurgitation.
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S U P P O R T I N G I N FO R M AT I O N Additional supporting information may be found online in the Supporting Information section at the end of the article. Movies S1A, S1B, S2A, S2B, S2C, S3, S4, S5, S6, S7, S8A, S8B, S9, S10A, S10BC, S10D, S11, S12, S13A, S13B, S14, S15, S16, S17A, S17B.
How to cite this article: Murray CSG, Salama AY, Akdogan RE, Harb S, Nahar T, Nanda NC. Assessment of tricuspid valve by two-and three-dimensional echocardiography with special reference to percutaneous repair and prosthetic valve implantation procedures. Echocardiography. 2018;35:1419– 1438. https://doi.org/10.1111/echo.14130
