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Tricuspid Regurgitation Due to Absent Tricuspid Valve Leaflet

Utility of Three-Dimensional Echocardiography

Amhaz, Hassan MD*; Kretzer, Adam MD; Podgoreanu, Mihai MD, FASE*; Glower, Donald MD; Nicoara, Alina MD, FASE*

doi: 10.1213/XAA.0000000000000700
Case Reports: Echo Rounds

From the *Department of Anesthesiology, Duke University, Durham, North Carolina; Department of Anesthesiology, Northwestern University, Chicago, Illinois; and Department of Surgery, Duke University, Durham, North Carolina.

Accepted for publication May 16, 2017.

Funding: Departmental.

The authors declare no conflicts of interest.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website.

Address correspondence to Alina Nicoara, MD, FASE, Department of Anesthesiology, Duke University, Durham, NC, 2301 Trent Dr, Durham, NC 27710. Address e-mail to

Written, informed consent was obtained from the patient for publication of this case report. A 28-year-old female presented with increasing dyspnea, lower extremity edema and ascites. She had a history of tricuspid valve (TV) endocarditis diagnosed and medically treated at an outside hospital 5 years before presentation for surgery. Preoperative transthoracic echocardiography (TTE) performed at an outside hospital showed severe tricuspid regurgitation (TR) and severe right ventricle (RV) and right atrium (RA) dilation. She was scheduled for TV surgery through an anterolateral thoracotomy approach.

Intraoperative transesophageal echocardiography (TEE) was performed using a 3D echocardiographic matrix-array probe (X7-2t transducer, Philips Healthcare, Andover, MA). 2D echocardiographic examination of the TV (Figure 1A, B; Supplemental Digital Content 1, Video 1, demonstrated the apparent absence of a TV leaflet, probably posterior, together with the corresponding subvalvular apparatus and normal appearance of the other 2 leaflets. Color flow Doppler interrogation of the TV showed a wide TR jet with a vena contracta width of 1.8 cm (Figure 1C; Supplemental Digital Content 1, Video 1, Continuous wave Doppler across the TV demonstrated a dense TR jet with a low peak velocity of 1.8 m/s reflective of the elevated RA pressure (Figure 1D). The spectral Doppler profile was of a triangular shape consistent with rapid equalization of the pressure between the RV and the RA due to the severity of regurgitation. Three-dimensional dataset of the TV was acquired starting from the mid-esophageal 4-chamber (ME-4C) view. The en-face view of the TV from the RA, obtained after cropping into the dataset, showed a large anterior leaflet, a small septal leaflet, and unequivocal absence of the posterior TV leaflet (Figure 2A; Supplemental Digital Content 2, Video 2, The tricuspid annulus was measured by multiplanar reconstruction of the 3D dataset as 3.8 cm septal-lateral diameter and 4.6 cm anterior-posterior diameter (Figure 2B). This information was related to the surgeon who planned for a repair with bicuspidization of the TV pending confirmation of these findings at surgical inspection.

Figure 1

Figure 1

Figure 2

Figure 2

The patient underwent tricuspid annuloplasty and valve repair with a 25 mm Tailor ring (St. Jude Medical, Inc, St. Paul, MN) and bicuspidization with suture plication of the posterior annulus, which approximated the gap at the missing posterior leaflet and brought the posterior edges of the anterior and septal leaflets together. After separation from cardiopulmonary bypass, intraoperative TEE showed good results of the repair with no residual regurgitation, no periannular leaks and mild tricuspid stenosis with a mean gradient of 4 mm Hg (Supplemental Digital Content 3, Video 3, There was no tissue resected during the repair; therefore, no pathological diagnosis was made.

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TR due to complete absence of a TV leaflet is very rare. To date, there have been only 2 reports of absent posterior tricuspid leaflet and 2 reports of absent anterior tricuspid leaflet.1–3 In the case presented, despite the patient’s medical history of endocarditis, the probable etiology of severe TR was the congenital absence of the posterior TV leaflet given the complete absence of the posterior leaflet and the corresponding subvalvular apparatus and the normal appearance of the other 2 leaflets.

The current guidelines recommend imaging of the TV using the standard ME-4C, ME RV inflow-outflow, and ME-modified bicaval views. TG basal RV, TG RV inflow-outflow, and TG RV inflow views may be useful for further interrogation.4 However, the echocardiographer should be aware of pitfalls and limitations when imaging the TV by 2D echocardiography. There are significant variations in TV leaflet, and annular dimensions. With the exception of the TG RV basal view, which enables visualization of all the TV leaflets in cross-section, only 2 of the 3 leaflets can be imaged in a single 2D view, with uncertainty regarding precise identification of the leaflets from the standard views using either 2D TTE or TEE. A review of TV imaging by TEE states that depending on the position, flexion, and rotation of the probe, a different pair of leaflets can be seen in the same view: septal-anterior or septal-posterior in the ME-4chC view, septal-posterior or anterior-posterior in the ME RV inflow-outflow, and anterior-posterior or anterior-septal in ME-modified bicaval view (Figure 3A).5

Figure 3

Figure 3

3D imaging allows immediate identification of the leaflets by examining the TV in an en-face fashion either from the RA or from the RV. Steps that will facilitate successful acquisition of a 3D dataset vary depending on the vendor used but generally include6 (i) find the best 2D window to image the TV, (ii) use a lower frequency to improve the appearance of the TV in the final dataset, due to the position of the TV in the far field, (iii) maintain overall gain and compression setting in mid-range, (iv) adjust focus of the beam at the level of the TV, (v) manipulate line density to medium or high to improve spatial resolution, especially if a multibeat acquisition is feasible to ensure adequate volume rate. Imaging of the TV by 3D TEE can also be challenging because of the thin appearance of the TV leaflets. The appearance of leaflet perforations may be due to echo dropout and should be correlated with 2D findings, as well as presence of blood flow by color flow Doppler.

Further postprocessing of a 3D dataset through multiplanar reconstruction enables correct identification of the TV anatomy by adjusting the position of the planes (Figure 3B, C), as well as accurate measurement of the septal-lateral and anterior-posterior dimensions of the tricuspid annulus (Figure 2B).

In conclusion, we present a case of severe TR due to absent posterior leaflet of the TV in which intraoperative TEE and specifically 3D imaging assisted in the accurate description of the TV pathology. Our findings helped in formulating a surgical plan and reinforced the high likelihood of achieving a successful repair, which was paramount in this young patient to avoid the possible complications associated with a TV replacement (ie, prosthesis degeneration and reoperation later in life or morbidity associated with anticoagulation). With all its limitations, 2D echocardiography remains the cornerstone of TV imaging; however, some of the challenges posed by imaging of the TV by 2D can be overcome by adding 3D echocardiography in a complementary fashion.

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Name: Hassan Amhaz, MD.

Contribution: This author helped analyze the data and write the manuscript.

Name: Adam Kretzer, MD.

Contribution: This author helped analyze the data and write the manuscript.

Name: Mihai V. Podgoreanu, MD, FASE.

Contribution: This author helped conduct the study and analyze the data.

Name: Donald D. Glower, MD.

Contribution: This author helped conduct the study.

Name: Alina Nicoara, MD, FASE.

Contribution: This author helped conduct the study, analyze the data, and write the manuscript.

This manuscript was handled by: Nikoloas J. Skubas, MD, DSc, FACC, FASE.

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