Incremental Value of the En Face View of the Tricuspid Valve by Two-Dimensional and Three-Dimensional Echocardiography for Accurate Identification of Tricuspid Valve Leaflets

Personalized Guidance of Edge-to-Edge Transcatheter Tricuspid Valve Repair by Multimodality Imaging

Background: Transcatheter edge-to-edge tricuspid valve repair (T-TEER) for tricuspid regurgitation (TR) is always guided by transesophageal echocardiography (TEE). As each patient has unique anatomy and acoustic window, adding transthoracic echocardiography (TTE) and cardiac CT could improve procedural planning and guidance. Objectives: We aimed to assess T-TEER success and outcomes of a personalized guidance approach, based on multimodality imaging (MMI) of patient-tailored four right-sided chamber views (four-right-ch), as depicted by CT, TTE, TEE and fluoroscopy. Methods: Patients were assigned to MMI or classical TEE guidance, depending on TTE acoustic window. In MMI patients, planning included cardiac CT, which determined the fluoroscopic angulations of the specific four-right-ch, while guidance relied heavily on TTE, with minimal intermittent TEE for leaflet grasping and result confirmation. Both TTE and TEE were matched to respective CT and fluoroscopy four-right-ch. TR severity and quality of life (QoL) parameters were assessed from baseline to 12 months. Results: A total of 40 T-TEER patients were included, with 17 procedures guided by MMI and 23 solely by TEE. Baseline characteristics were similar between groups, e.g., age (83.1 ± 4.1 vs. 81 ± 5.3, p = 0.182) or STS-Score (11.1 ± 7.4% vs. 10.6 ± 5.9%, p = 0.813). The primary efficacy endpoint of ≥one-grade TR reduction at 30 days was 94% (16/17) in MMI vs. 91% (21/23) in TEE patients, with two or more TR grade reduction in 65% vs. 52% (p = 0.793). Device success was overall 100%, with no device-related complications, but three TEE-associated cases of gastrointestinal bleeding in the TEE-only group. By 12 months, all 15 MMI and 19 TEE survivors improved NYHA functional class and QoL, e.g., Kansas City Cardiomyopathy Questionnaire Score Δ29.6 ± 6.7 vs. 21.9 ± 5.8 (p = 0.441) pts., 6-min walk distance Δ101.5 ± 36.4 vs. 85.7 ± 32.1 (p = 0.541) meters. Conclusions: In a subset of patients with good TTE acoustic window, MMI guidance of T-TEER is effective and seems to avoid gastroesophageal injuries caused by TEE probe manipulation. TR reduction, irrespective of guidance method, impacts long-term QoL.

Female Patient Presenting With Increasing Pedal Edema

This case report discusses a diagnosis of congenital bicuspid-tricuspid valve in a female patient in their 20s with a history of heart transplant.

Tricuspid valve disease and cardiac implantable electronic devices

The role of cardiac implantable electronic device (CIED)-related tricuspid regurgitation (TR) is increasingly recognized as an independent clinical entity. Hence, interventional TR treatment options continuously evolve, surgical risk assessment and peri-operative care improve the management of CIED-related TR, and the role of lead extraction is of high interest. Furthermore, novel surgical and interventional tricuspid valve treatment options are increasingly applied to patients suffering from TR associated with or related to CIEDs. This multidisciplinary review article developed with electrophysiologists, interventional cardiologists, imaging specialists, and cardiac surgeons aims to give an overview of the mechanisms of disease, diagnostics, and proposes treatment algorithms of patients suffering from TR associated with CIED lead(s) or leadless pacemakers.

Transthoracic and transoesophageal echocardiography for tricuspid transcatheter edge-to-edge repair: a step-by-step protocol

Tricuspid regurgitation (TR) carries an unfavourable prognosis and often leads to progressive right ventricular (RV) failure. Secondary TR accounts for over 90% of cases and is caused by RV and/or tricuspid annulus dilation, in the setting of left heart disease or pulmonary hypertension. Surgical treatment for isolated TR entails a high operative risk and is seldom performed. Recently, transcatheter edge-to-edge repair (TEER) has emerged as a low-risk alternative treatment in selected patients. Although the experience gained from mitral TEER has paved the way for the technique's adaptation to the tricuspid valve (TV), its anatomical complexity necessitates precise imaging. To this end, a comprehensive protocol integrating 2D and 3D imaging from both transthoracic echocardiography (TTE) and transoesophageal echocardiography (TOE) plays a crucial role. TTE allows for an initial morphological assessment of the TV, quantification of TR severity, evaluation of biventricular function, and non-invasive haemodynamic evaluation of pulmonary circulation. TOE, conversely, provides a detailed evaluation of TV morphology, enabling precise assessment of TR mechanism and severity, and represents the primary method for determining eligibility for TEER. Once a patient is considered eligible for TEER, TOE, alongside fluoroscopy, will guide the procedure in the catheterization lab. High-quality TOE imaging is crucial for patient selection and to achieve procedural success. The present review examines the roles of TTE and TOE in managing patients with severe TR eligible for TEER, proposing the step-by-step protocol successfully adopted in our centre.

Tricuspid Regurgitation in Acute Heart Failure: Predicting Outcome Using Novel Quantitative Echocardiography Techniques

Background: The prognostic impact of tricuspid regurgitation (TR) in acute heart failure (AHF) remains uncertain. Methods: We retrospectively assessed 418 consecutive AHF patients who underwent comprehensive echocardiographic assessment within 24 h of study recruitment. TR was quantitatively assessed with 3 guideline-directed measures: regurgitant volumes (RgVol), effective regurgitant orifice area (ERO) and vena contracta (VC) diameter. Disproportionate TR was assessed by the ratio of the VC diameter to the tricuspid annulus diameter (VC/TA) ≥ 0.24. Results: The prevalence of significant (i.e., >mild) TR differed when various standard assessment parameters were applied to quantification: RgVol 50.3% (173/344), ERO 75.6% (260/344) and VC diameter 94.6% (335/354). None were able to delineate those at excess risk of all-cause 2-year mortality using guideline-directed cut-offs of mild, moderate and severe TR. Using a cut-off of VC/TA ≥ 0.24, we identified that 36.9% (130/352) had “disproportionate” TR. Disproportionate TR was associated with an excess risk of mortality at 2 years compared to proportionate TR; HR 1.48 (95% CI 1.06−2.06 [p = 0.02]) which was not significant on multivariate assessment (p = 0.94). Conclusions: TR was not associated with outcome in AHF using guideline measures. A new assessment of “Disproportionate” TR carries a higher risk than proportionate TR but was not related to outcome based on multivariate analysis. Further research is needed to quantify TR more effectively to identify cut-offs for future guidelines and disproportionate TR may be an important part of Heart Failure 2.0.

Echocardiographic Assessment of Right Ventricular Function in Paediatric Heart Disease: A Practical Clinical Approach

As the right ventricle (RV) plays an integral role in different paediatric heart diseases, the accurate assessment of RV size and function is essential in the diagnosis, management, and prognostication of congenital and acquired cardiac lesions. Yet, echocardiographic evaluation of the RV is challenging because of its complex and variable morphology, its different physiology compared with the left ventricle, and its capability to adapt to different loading conditions associated with congenital and acquired heart diseases within certain ranges. Reliable echocardiographic detection of RV systolic and diastolic dysfunction remains challenging while important for patient management. This review provides an updated, practical approach to assessing RV function in structurally normal hearts and in children with common congenital heart defects and in those with pulmonary hypertension. We also review the impact of tricuspid valve function on RV functional parameters. There is no single functional RV parameter that uniquely describes RV function; instead a combination of different parameters is recommended in clinical practice. Qualitative and quantitative analysis of RV function will be reviewed including more recent techniques such as speckle tracking and 3D echocardiography.

Insights from 3D Echocardiography in Hypoplastic Left Heart Syndrome Patients Undergoing TV Repair

BACKGROUND

Tricuspid regurgitation (TR) in hypoplastic left heart syndrome (HLHS) is associated with morbidity and mortality. TR mechanisms and the impact of tricuspid valve repair (TVR) are unclear. We examined HLHS TR mechanisms, TVR's impact on tricuspid valve (TV), and features of poor TVR durability.

METHODS

We retrospectively compared 35 HLHS TVR cases and 35 age/stage-matched HLHS controls who do not undergo TVR. Pre-operative 3-dimensional echocardiography (3DE) assessed overall TV morphology (prolapse, normal, tethered), leaflet morphology, vena contracta area, and TR location. Two-dimensional echocardiography measured TV annulus diameter, RV fractional area change (RVFAC), sphericity, and TR grade at three time points (pre-op, early post-op, and latest follow-up).

RESULTS

Pre-op, TVR group, and controls had no difference in age, RV function or shape, or TV dimension. TVR group most commonly had anterior leaflet prolapse followed by septal leaflet prolapse or tethering. TR jet arises centrally (63%) and anterior septally (26%). Posterior annuloplasty (69%), commissuroplasty (37%), and leaflet repair (37%) were surgical techniques commonly performed. At early post-op, TR grade and TV annulus decreased. At latest follow-up, TV annulus remained reduced; however, 50% had significant TR. 25% required TV reoperation. Larger vena contracta at TVR was associated with significant TR.

CONCLUSION

HLHS patients undergoing TVR had more anterior leaflet prolapse and central TR. While TVR initially reduces annular size and TR grade, 50% redevelop significant TR despite maintained annular reduction. The association of greater TR severity prior to repair with post-op recurrence raises the consideration for earlier repair of TR in HLHS patients.

Multi-modality imaging assessment of native valvular regurgitation: an EACVI and ESC council of valvular heart disease position paper

Valvular regurgitation represents an important cause of cardiovascular morbidity and mortality. Imaging is pivotal in the evaluation of native valve regurgitation and echocardiography is the primary imaging modality for this purpose. The imaging assessment of valvular regurgitation should integrate quantification of the regurgitation, assessment of the valve anatomy and function, and the consequences of valvular disease on cardiac chambers. In clinical practice, the management of patients with valvular regurgitation largely relies on the results of imaging. It is crucial to provide standards that aim at establishing a baseline list of measurements to be performed when assessing native valve regurgitation. The present document aims to present clinical guidance for the multi-modality imaging assessment of native valvular regurgitation.

Recent advances in multimodality imaging of the tricuspid valve

INTRODUCTION

The tricuspid valve (TV) and the right heart chambers are complex three-dimensional structures that are difficult to assess using tomographic imaging techniques. The progressive aging of the general population and the advancements in treating left-sided heart diseases by transcatheter procedures have contributed to the tricuspid regurgitation (TR) becoming a major public health problem associated with progression to refractory heart failure and poor outcome. Recent advances in multimodality cardiac imaging allow a better understanding of the pathophysiology of TR that may translate in better management of patients.

AREAS COVERED

Three-dimensional echocardiography, cardiac magnetic resonance, and computed tomography provide complementary information to i. assess the TV complex; ii. identify the etiology and the mechanisms of TR; iii. evaluate its severity and hemodynamic consequences; iv. explore the remodeling of the right heart chambers; and v. properly plan, guide, and monitor the transcatheter interventions aimed to reduce the severity of TR.

EXPERT OPINION

We need thorough understanding of both the TV and the right heart chamber geometry and function to understand the pathophysiology of TR. The integrated use of multimodality cardiac imaging is pivotal to assess patients with TR and to identify tailored and timely treatment of TR in properly selected patients.

Case Report: Assessing the Position of Pacemaker Leads via Transthoracic Echocardiography: Additional Value of the Subcostal En Face View

There is an association between presence of cardiac implantable electronic devices (CIED) and development of tricuspid regurgitation (TR). Mechanisms proposed to explain CIED-induced TR can be classified as implantation-related, lead-related, and pacing-related. Lead-related TR results from the direct interaction of the lead with the tricuspid valve (TV). The localization of the lead at the TV level directly influences the probability of subsequent development of significant TR. A transthoracic subcostal en face view of the TV can be acquired in most patients through a 90° rotation from the subcostal 4-chamber view with clear anatomic delineation of the TV and the commissures including lead position. This case-series presents three examples where the transthoracic en face view could add incremental information on the position of the pacemaker leads and on the mechanism of TR.

Conclusion: When performing transthoracic echocardiography in patients with trans-tricuspid CIED lead(s), an en face view of the TV with exact reporting of the position of the lead(s) should be included.

Transesophageal three-dimensional echocardiographic guidance for pacemaker lead extraction

BACKGROUND

The ability of transesophageal three-dimensional echocardiography (3DE) to aid in pacemaker lead extraction has not yet been evaluated. 3DE provides real-time evaluation of intracardiac anatomy and the location of pacemaker leads in greater detail than either fluoroscopy or -two-dimensional echocardiography (2DE), aiding in the extraction of such leads, which can be potentially dangerous. We sought to investigate the feasibility and utility of 3DE to visualize intracardiac anatomy and pacemaker leads, and to assist in lead extraction procedures.

METHODS

We utilized 3DE in nine encounters for eight different patients, to visualize intracardiac anatomy and leads before, during, and after extraction to evaluate the feasibility and utility to aid in the procedure and evaluate for potential sequelae.

RESULTS

3DE was able to identify pertinent intracardiac anatomy and leads in all cases. 3DE detected procedural complications or altered management in five of nine encounters (five of eight patients); this included detection of an avulsed papillary muscle, tricuspid valve leaflet damage, and cast/thrombus after lead removal, as well as adjustment of excess lead slack to avoid future valve damage, or risk stratification of lead removal.

CONCLUSION

3DE is feasible and adds utility to lead extraction cases by visualizing intracardiac anatomy and leads beyond fluoroscopy or 2DE, providing real-time information during extraction, and identifying potential complications.

Tricuspid Regurgitation in Hypoplastic Left Heart Syndrome: Three-Dimensional Echocardiography Provides Additional Information in Describing Jet Location

BACKGROUND

Twenty-five percent of patients with hypoplastic left heart syndrome (HLHS) require tricuspid valve (TV) repair. The location of tricuspid regurgitation (TR) is important in determining the type of repair performed. Studies using three-dimensional echocardiography (3DE) have reported a high incidence of error on two-dimensional echocardiography (2DE) for the identification of TV leaflets. The aim of this study was to compare assessment of TR on 3DE and 2DE in patients with HLHS (jet location, TR grade, and reproducibility).

METHODS

A retrospective, single-center review was performed. Fifty-six patients with HLHS with available two-dimensional and three-dimensional echocardiograms, and mild or greater TR, were included. TR location, grade, vena contracta area, and TV annular diameter were measured on 2DE and 3DE. Reproducibility was assessed by blinded reviewers.

RESULTS

Three-dimensional echocardiography identified the primary jet location as central (57%) followed by anteroseptal (36%). There was poor agreement between findings on 3DE and 2DE for jet location (κ = 0.05; 95 CI, -0.08 to 0.19). Interobserver reproducibility for location on 3DE was excellent (κ = 0.8), whereas reproducibility for 2DE was poor (κ = 0.32). The most common jet location pre-Norwood and pre-Glenn was central (70%), whereas pre-Fontan and post-Fontan, jet location was central (45%) and anteroseptal (48%). Vena contracta area on 2DE correlated moderately with vena contracta area on 3DE (r = 0.60, P < .0001). TV annular diameters on 2DE and 3DE for lateral (r = 0.85, P < .0001) and anteroposterior (r = 0.74, P = .001) dimensions were strongly correlated.

CONCLUSIONS

In children with HLHS, assessment of TR location on 2DE had poor agreement with assessment on 3DE and was poorly reproducible. In contrast, TR jet location on 3DE was highly reproducible. Pre-Glenn, a central TR jet was the most common, while post-Glenn, central and anteroseptal locations were equal, highlighting the importance of preoperative identification of TR jet location in patients with HLHS.

A pilot in silico modeling-based study of the pathological effects on the biomechanical function of tricuspid valves

Current clinical assessment of functional tricuspid valve regurgitation relies on metrics quantified from medical imaging modalities. Although these clinical methodologies are generally successful, the lack of detailed information about the mechanical environment of the valve presents inherent challenges for assessing tricuspid valve regurgitation. In the present study, we have developed a finite element-based in silico model of one porcine tricuspid valve (TV) geometry to investigate how various pathological conditions affect the overall biomechanical function of the TV. There were three primary observations from our results. Firstly, the results of the papillary muscle (PM) displacement study scenario indicated more pronounced changes in the TV biomechanical function. Secondly, compared to uniform annulus dilation, nonuniform dilation scenario induced more evident changes in the von Mises stresses (83.8-125.3 kPa vs 65.1-84.0 kPa) and the Green-Lagrange strains (0.52-0.58 vs 0.47-0.53) for the three TV leaflets. Finally, results from the pulmonary hypertension study scenario showed opposite trends compared to the PM displacement and annulus dilation scenarios. Furthermore, various chordae rupture scenarios were simulated, and the results showed that the chordae tendineae attached to the TV anterior and septal leaflets may be more critical to proper TV function. This in silico modeling-based study has provided a deeper insight into the tricuspid valve pathologies that may be useful, with moderate extensions, for guiding clinical decisions. NOVELTY STATEMENT: The novelties of the research are summarized below: A comprehensive in silico pilot study of how isolated functional tricuspid regurgitation pathologies and ruptured chordae tendineae would alter the tricuspid valve function; An extensive analysis of the tricuspid valve function, including mechanical quantities (eg, the von Mises stress and the Green-Lagrange strain) and clinically-relevant geometry metrics (eg, the tenting area and the coaptation height); and A developed computational modeling pipeline that can be extended to evaluate patient-specific tricuspid valve geometries and enhance the current clinical diagnosis and treatment of tricuspid regurgitation.

Left-sided congenitally unguarded tricuspid valve with congenitally corrected transposition of the great arteries: A rare diagnosis confirmed by three-dimensional echocardiography

Left-sided unguarded tricuspid valve disease with congenitally corrected transposition of the great arteries (ccTGA) is a rare cardiac malformation, only reported a few times in the literature. Two-dimensional echocardiography (2DE) uses standard views to diagnose tricuspid valve disease. Advanced imaging techniques, such as three-dimensional echocardiography, allow for simultaneous visualization of the tricuspid valve annulus and all leaflets. Three-dimensional echocardiography (3DE) may be useful in distinguishing unguarded tricuspid valve orifice from other forms of tricuspid valve disease.

A Case of Severe Tricuspid Regurgitation Related to Traumatic Papillary Muscle Rupture

A 25-year-old male presented after a motor vehicle accident with tricuspid valve (TV) regurgitation, due to a flail TV secondary to papillary muscle rupture. We highlight the importance of three-dimensional echocardiographic imaging of the tricuspid valve and its utility in aiding a successful surgical repair.

3-Dimensional Echocardiography in Imaging the Tricuspid Valve

Tricuspid regurgitation (TR) is an independent predictor of death. Lately, emerging technologies for the treatment of TR have increased the interest of physicians. Due to the complex 3-dimensional (3D) geometry of the tricuspid valve (TV) and its anterior position in the mediastinum, conventional 2D echocardiography is unsuitable to study the anatomy and pathophysiologic mechanisms of the regurgitant TV. 3D echocardiography has emerged as a very cost-effective imaging modality with which to: 1) visualize the TV anatomy; 2) define the mechanism of TR; 3) measure the size and geometry of the tricuspid annulus; 4) analyze the anatomic relationships between TV apparatus and surrounding cardiac structures; 5) assess volumes and function of the right atrium and ventricle; and 6) plan surgical repair or guide and monitor transcatheter interventional procedures.

Imaging Needs in Novel Transcatheter Tricuspid Valve Interventions

The advent of novel transcatheter therapies for severe tricuspid regurgitation (TR) has attracted much attention. Novel 3-dimensional imaging techniques have permitted analysis of the tricuspid valve (TV) anatomy from unparalleled views and better understanding of the underlying pathophysiology of TR. Grading TR and assessment of right ventricular function remain challenging, and although 2-dimensional echocardiography is the mainstay imaging technique to evaluate patients with severe TR the use of 3-dimensional echocardiography and cardiovascular magnetic resonance is increasing. The number of transcatheter interventions for TR is growing, and procedural success relies significantly on the pre-procedural evaluation of the anatomy of the TV, etiology and severity of TR, right ventricular size and function, and importantly, the anatomic relationships of the TV. The role of multimodality imaging in patient selection and procedural planning for transcatheter TV repair is reviewed.

Tricuspid valve imaging

The right ventricle and tricuspid valve (TV) have long been neglected by cardiologists. Functional tricuspid regurgitation (TR) is nowadays the most common cause of severe TR and is emerging as a prognostic factor in many heart diseases. A multimodality imaging approach is fundamental for defining the pathophysiology of TR, using both two-dimensional and three-dimensional echocardiography, as well as CT scan. In particular, 3D echocardiography can characterize TV apparatus and tricuspid annulus; CT offers complementary information about annular structure, and its relationship with the right coronary artery. The following review will describe TV anatomy, define transthoracic and transesophageal echocardiographic views for evaluating TV morphology, function and TR grading with some clues on interventional perspectives.

Interventional Imaging of the Tricuspid Valve

Nowadays, reasonable transcatheter tricuspid valve (TV) interventions are emerging as therapeutic options for functional tricuspid regurgitation (TR). The preprocedural planning is based on a multimodality imaging approach, which aims to (1) define the mechanisms of TR, (2) characterize TV morphology, (3) analyze the anatomic relationship between the TV apparatus and other structures, and (4) determine the size of the tricuspid annulus and vena cavae. Intraprocedural guidance is based mainly on transesophageal echocardiography (seldom transthoracic) and fluoroscopy, with the recent introduction of fusion imaging.

Current Clinical Applications of Three-Dimensional Echocardiography: When the Technique Makes the Difference

Advances in ultrasound, computer, and electronics technology have permitted three-dimensional echocardiography (3DE) to become a clinically viable imaging modality, with significant impact on patient diagnosis, management, and outcome. Thanks to the inception of a fully sampled matrix transducer for transthoracic and transesophageal probes, 3DE now offers much faster and easier data acquisition, immediate display of anatomy, and the possibility of online quantitative analysis of cardiac chambers and heart valves. The clinical use of transthoracic 3DE has been primarily focused, albeit not exclusively, on the assessment of cardiac chamber volumes and function. Transesophageal 3DE has been applied mostly for assessing heart valve anatomy and function. The advantages of using 3DE to measure cardiac chamber volumes derive from the lack of geometric assumptions about their shape and the avoidance of the apical view foreshortening, which are the main shortcomings of volume calculations from two-dimensional echocardiographic views. Moreover, 3DE offers a unique realistic en face display of heart valves, congenital defects, and surrounding structures allowing a better appreciation of the dynamic functional anatomy of cardiac abnormalities in vivo. Offline quantitation of 3DE data sets has made significant contributions to our mechanistic understanding of normal and diseased heart valves, as well as of their alterations induced by surgical or interventional procedures. As reparative cardiac surgery and transcatheter procedures become more and more popular for treating structural heart disease, transesophageal 3DE has expanded its role as the premier technique for procedure planning, intra-procedural guidance, as well as for checking device function and potential complications after the procedure.

Percutaneous Treatment of the Tricuspid Valve Disease: New Hope for the "Forgotten" Valve

Tricuspid valve disease is a frequent condition but is currently undertreated. A limited number of patients undergo an isolated surgical tricuspid repair, and this intervention is associated with poor outcomes, especially in patients with previous cardiac surgery. Most patients are only medically treated, despite the impact of severe tricuspid regurgitation on functional status and long-term survival. Transcatheter therapies represent a promising alternative for patients with severe tricuspid regurgitation and high surgical risk. In the last few years, several percutaneous alternatives have been developed for the treatment of functional tricuspid regurgitation. Imaging techniques play an indispensable role in patient selection, procedural guidance and follow-up. The current available transcatheter options for native tricuspid valve disease can be divided into 3 main groups: heterotopic caval valve implantation, annuloplasty devices, and coaptation devices. In patients with previous tricuspid valve surgery, transcatheter valve-in-valve and valve-in-ring procedures have been reported. This review provides a detailed analysis of the novel transcatheter alternatives for the treatment of tricuspid valve disease that have already been successfully implanted in humans, as well as the most important aspects of tricuspid valve anatomy and imaging assessment.

State-of-the-Art Review of Echocardiographic Imaging in the Evaluation and Treatment of Functional Tricuspid Regurgitation

Functional or secondary tricuspid regurgitation (TR) is the most common cause of severe TR in the Western world. The presence of functional TR, either isolated or in combination with left heart disease, is associated with unfavorable natural history. Surgical mortality for isolated tricuspid valve interventions remains higher than for any other single valve surgery, and surgical options for repair do not have consistent long-term durability. In addition, as more patients undergo transcatheter left valve interventions, developing transcatheter solutions for functional TR has gained greater momentum. Numerous transcatheter devices are currently in early clinical trials. All patients require an assessment of valve morphology and function, and transcatheter devices typically require intraprocedural guidance by echocardiography. The following review will describe tricuspid anatomy, define echocardiographic views for evaluating tricuspid valve morphology and function, and discuss imaging requirements for the current transcatheter devices under development for the treatment of functional TR.

Comprehensive Two-Dimensional Interrogation of the Tricuspid Valve Using Knowledge Derived from Three-Dimensional Echocardiography

BACKGROUND

Accurate identification of tricuspid valve (TV) leaflets by two-dimensional (2D) transthoracic echocardiography is difficult because of variability in the intersection between the imaging plane and leaflets. Using information obtained from multiplanar reconstruction (MPR) of three-dimensional (3D) data sets, the investigators sought to define "novel" 2D views that would allow targeted interrogation of TV leaflets using 2D transthoracic echocardiography.

METHODS

Images of the TV in the standard 2D views (apical four chamber, right ventricular focused, right ventricular inflow, and parasternal short axis) and 3D data sets were acquired from the same probe position in 106 adults. Three-dimensional MPR was used to determine which leaflet combination was seen in the 2D image: anterior and septal, anterior and posterior, anterior alone, or posterior and septal. Using this analysis, 2D landmarks were identified to define nonstandard TV views tailored to depict specific leaflets. Two-dimensional images in these views and 3D data sets were then prospectively collected in 54 additional patients. Three independent readers analyzed these 2D views to determine TV leaflet combinations, and their interpretation was compared with 3D MPR-derived reference.

RESULTS

Three-dimensional MPR views made it possible to define six nonstandard 2D views on the basis of anatomic clues and landmarks, which consistently depicted all the aforementioned leaflet combinations. When these six views were prospectively tested, the agreement of TV leaflet identification against 3D MPR was excellent (κ = 0.88, κ = 0.93, and κ = 0.98).

CONCLUSION

The nonstandard 2D views defined in this study allow accurate TV leaflet identification and may thus be useful when localization of TV leaflet pathology is clinically important.

Tricuspid Regurgitation: 2015 Reflections and Re-evaluation

OPINION STATEMENT

The tricuspid valve is, in fact, anatomically and functionally more complex than its left-sided counterpart-the mitral valve. Patients may develop tricuspid regurgitation from a variety of mechanisms. While current guidelines provide a very basic approach to tricuspid regurgitation (TR) evaluation, more recent techniques, particularly 3D echocardiography, have provided novel insights into how we can ascertain the mechanism and severity of tricuspid regurgitation, how the tricuspid valve adapts to disease and, importantly, how we assess the effects of TR on right ventricular size and function. We anticipate that these advances will soon yield dividends that will help us decide on approaches to treatment and timing of surgery.