Secondary Logo

Journal Logo

Two-Dimensional Transesophageal Echocardiographic Imaging of the Tricuspid Valve

Rehfeldt, Kent H. MD

doi: 10.1213/ANE.0b013e3182458af2
Cardiovascular Anesthesiology: Echo Didactics
Free
SDC

Published ahead of print January 16, 2012 Supplemental Digital Content is available in the text.

From the Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota.

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 Web site (www.anesthesia-analgesia.org).

The author declares no conflicts of interest.

Reprints will not be available from the author.

Address correspondence to Kent H. Rehfeldt, MD, Department of Anesthesiology, Mayo Clinic, 200 First St. SW, Rochester, MN 55905. Address e-mail to Rehfeldt.kent@mayo.edu.

Accepted December 1, 2011

Published ahead of print January 16, 2012

Back to Top | Article Outline

INDEX CASE

A 56-year-old man with mitral regurgitation presents for mitral valve repair. In addition to severe mitral regurgitation, the preoperative transthoracic echocardiogram (TTE) reveals a possible mass on a tricuspid valve (TV) leaflet and moderate tricuspid regurgitation. The surgeon inquires whether the TV mass is present and from which leaflet it arises. Furthermore, the surgeon asks whether the tricuspid annulus (TA) is dilated.

Back to Top | Article Outline

DISCUSSION

For several reasons, the study of TV imaging using transesophageal echocardiography (TEE) is difficult for some clinicians. First, TV imaging has received less literature attention compared with the left-sided valves.1 Second, it can be difficult to obtain satisfactory 2-dimensional (2D) views of the TV using TEE in some patients.2 Imaging difficulties relate to the relative distance between the valve and transducer in midesophageal (ME) views and individual variation in leaflet size. Additionally, a less favorable angle of interrogation and thinner leaflets combine to make the TV less echogenic compared with the mitral valve. Acoustic shadowing may degrade ME TV images in the setting of mitral annular calcification, prosthetic valves, medical devices such as pacemaker leads or pulmonary artery catheters, or a lipomatous atrial septum. Third, the literature presents contradictory information regarding the echocardiographic visualization of the TV. For example, one textbook reports that the leaflet visualized adjacent to the right ventricular (RV) free wall in an ME 4-chamber view is the anterior leaflet.2 In contrast, a task force report indicates that the posterior leaflet occupies this position.3 Yet another textbook describes this as the “nonseptal” leaflet.4 Other authors disagree as to whether the septal2 or posterior5 leaflet is smallest.

Back to Top | Article Outline

Anatomy

The TV apparatus includes 3 leaflets named anterior, posterior, and septal. Variability in leaflet size is common, although the anterior leaflet is the largest and occupies a relatively constant position. The commissures between the 3 leaflets are less distinct compared with other valves (Video 1, see Supplemental Digital Content 1, http://links.lww.com/AA/A347). In fact, Martinez et al.1 refer to a “skirt” of leaflet tissue encircling the annulus. Because the septal leaflet is anchored by the fibrous trigones, tricuspid annular dilation occurs primarily along the attachments of the anterior and posterior leaflets.6 Up to 3 papillary muscles with multiple heads may be identified. The anterior papillary muscle is larger than its posterior and septal counterparts. In addition, direct chordal attachments between the ventricular septum and septal leaflet represent one of the most constant features of TV anatomy.1 There are chordal attachments from the anterior papillary muscle to the anterior and posterior leaflets. The posterior papillary muscle provides chordae to the posterior and septal leaflets, whereas the septal papillary muscle provides chordae to the septal and anterior leaflets.

Recognition of its more apical position compared with the mitral valve facilitates identification of the TV. Excessive apical offset (an indexed distance between the septal insertion of the mitral valve and TV exceeding 8 mm/m2) indicates Ebstein anomaly. The largest of the 4 cardiac valves, the area bounded by the TA in normal adults, is 10.0 ± 2.9 cm2, although the area of the triangular orifice of the open leaflets in diastole averages 4.8 ± 1.6 cm2.5

Back to Top | Article Outline

TEE Imaging

The TV, being large and having an irregular shape, requires a methodical imaging approach, best done by sweeping the imaging plane across the valve annulus with TEE probe manipulations, which include advancement/withdrawal, turning, and rotation of the multiplane angle. Typically, an ME 4-chamber view displays the anterior leaflet adjacent to the RV free wall (Figs. 1 and 2) and the septal leaflet adjacent to the ventricular septum.3 However, additional retroflexion or advancement of the probe may bring the posterior leaflet into view (Figs. 1 and 2). Increasing the multiplane angle to approximately 50° to 70° develops the ME RV inflow-outflow view (Video 2, see Supplemental Digital Content 2, http://links.lww.com/AA/A348). In this view, the posterior leaflet is visualized adjacent to the RV free wall and either the septal or anterior leaflet is seen next to the aortic valve, depending on the degree of probe anteflexion or rightward probe turning (Fig. 1). By further increasing the multiplane angle to approximately 110° to 120° along with slight additional rightward turning of the probe, a modified bicaval view may be developed with the posterior leaflet displayed on the left side of the image near the coronary sinus (Fig. 3). In this view, the anterior leaflet appears on the right side of the image near the right atrial appendage. Probe anteflexion or an increase in the multiplane angle may bring the septal leaflet into view near the coronary sinus at the left side of the image (Fig. 3). The relationship of the TV to right atrial structures as seen from a bicaval orientation is presented in Figure 4. The anterior leaflet is adjacent to the right atrial appendage whereas the septal/posterior commissure is located near the orifice of the coronary sinus.

Figure 1

Figure 1

Figure 2

Figure 2

Figure 3

Figure 3

Figure 4

Figure 4

Useful TV views may also be obtained from the transgastric (TG) window. Starting with a TG midpapillary left ventricular short-axis view, the probe is turned rightward and the multiplane angle is increased to between 20° and 50° (Video 1, see Supplemental Digital Content 1, http://links.lww.com/AA/A347). This short-axis image of the TV represents the only 2D TEE view that displays all 3 leaflets simultaneously. The application of retroflexion typically allows visualization of the papillary muscles in short axis. Without moving the probe from the TV short-axis view, the multiplane angle may be increased to approximately 90° to 120° to develop an orthogonal view of the valve, the TG RV inflow view (Video 3, see Supplemental Digital Content 3, http://links.lww.com/AA/A349). In this view, the anterior and posterior leaflets can be seen with the posterior leaflet closest to the TEE probe and inferior border of the heart. This view also affords good visualization of the papillary muscles in long axis. Various TEE views, the approximate multiplane angles, and probe movement modifications used to visualize different leaflets are summarized in Table 1.

Table 1

Table 1

Although the TA can be measured in a variety of echocardiographic views, the 4-chamber view has most often been used. After scrolling through diastolic frames to find the largest annular diameter, calipers are placed using an inner-edge to inner-edge technique. Indexed (body surface area) TA diameters exceeding 2.1 cm/m2 (approximately 3.5 cm for a body surface area of 1.7 m2) have been used to recommend TV repair in the setting of mitral valve disease.7 However, visualization of the ellipsoid, saddle-shaped TA with 3D TTE8 has led to the recognition of both a major and minor annular axis.6 Interestingly, the 4-chamber view does not correspond to either the major or minor axis and considerably underestimates the major axis.6 Normal TA measurements by 3D TTE are approximately 4.0 cm.5 By comparing intraoperative TEE measurements in multiple views with those obtained by surgical measurement, Maslow et al.9 discovered that the TG RV inflow view yielded TA values with better agreement and correlation compared with ME TEE views.

Fractional shortening (FS) of the TA can be measured using 2D echocardiography and a 4-chamber view. Similar to calculations for the left ventricle, FS of the TA can be expressed as TAdiastole − TAsystole/TAdiastole. Values of FS in individuals with normal TA dimensions of 13.5 ± 5.7 have been reported.6

Accurate identification of the tricuspid leaflets and recognition of annular dilation may prove quite helpful in surgical planning. Because of its progressive nature, some authors advocate surgical intervention in the setting of TV annular dilation even if the tricuspid regurgitation is not severe.10 A methodical approach to 2D TV imaging that uses multiple views and uses both ME and TG windows to view the leaflets in both long and short axis is recommended.

Back to Top | Article Outline

DISCLOSURES

Name: Kent H. Rehfeldt, MD.

Contribution: Study design, manuscript preparation.

Back to Top | Article Outline

APPENDIX: VIDEO LEGENDS

Video 1. Development of the transgastric tricuspid short-axis view with labeling of the 3 leaflets. From a midesophageal position, the probe is advanced into the stomach and the multiplane angle is increased to approximately 20° to 50°. Rightward probe turning may be needed to image the tricuspid valve in short axis. The commissures (C) and right fibrous trigone (T) are also labeled.

Video 2. Development of the midesophageal (ME) right ventricular inflow-outflow view demonstrating the positions of the posterior and either septal or anterior (depending on probe anteflexion) tricuspid leaflets. Beginning with an ME 4-chamber view, the multiplane angle is increased to approximately 50° to 70°. Turning of the probe rightward may be needed to fully develop this view.

Video 3. Development of the transgastric (TG) right ventricular inflow view demonstrating the anterior and posterior tricuspid leaflets in long axis. Beginning with a TG left ventricular short-axis view, the multiplane angle is increased to approximately 90° to 120° and the probe is turned rightward.

Back to Top | Article Outline

REFERENCES

1. Martinez RM, O'Leary PW, Anderson RH. Anatomy and echocardiography of the normal and abnormal tricuspid valve. Cardiol Young 2006;16:4–11
2. Armstrong WF, Ryan T. Feigenbaum's Echocardiography. 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2009
3. Shanewise JS, Cheung AT, Aronson S, Stewart WJ, Weiss RL, Mark JB, Savage RM, Sears-Rogan P, Mathew JP, Quinones MA, Cahalan MK, Savino JS. ASE/SCA guidelines for performing a comprehensive intraoperative multiple transesophageal echocardiography examination: recommendations of the American Society of Echocardiography Council for Intraoperative Echocardiography and the Society of Cardiovascular Anesthesiologists Task Force for Certification in Perioperative Transesophageal Echocardiography. J Am Soc Echocardiogr 1999;12:884–900
4. Moukarbel GV, Abchee AB. Tricuspid and pulmonary valves. In: Mathew JP, Swaminathan M, Ayoub CM eds. Clinical Manual and Review of Transesophageal Echocardiography. 2nd ed. New York: McGraw-Hill, 2010:222–39
5. Anwar AM, Geleijnse ML, Soliman OI, McGhie JS, Frowijn R, Nemes A, van den Bosch AE, Galema TW, ten Cate FJ. Assessment of normal tricuspid valve anatomy in adults by real-time three-dimensional echocardiography. Int J Cardiovasc Imaging 2007;23:717–24
6. Anwar AM, Geleijnse ML, ten Cate FJ, Meijboom FJ. Assessment of tricuspid valve annulus size, shape and function using real-time, three-dimensional echocardiography. Interact Cardiovasc Thorac Surg 2006;5:683–7
7. Colombo T, Russo C, Ciliberto GR, Lanfranconi M, Bruschi G, Agati S, Vitali E. Tricuspid regurgitation secondary to mitral valve disease: tricuspid annulus function as guide to tricuspid valve repair. Cardiovasc Surg 2001;9:369–77
8. Badano LP, Agricola E, de Isla LP, Giafagna P, Zamorano JL. Evaluation of the tricuspid valve morphology and function by transthoracic real-time three-dimensional echocardiography. Eur J Echocardiogr 2009;10:477–84
9. Maslow AD, Schwarz C, Singh AK. Assessment of the tricuspid valve: a comparison of four transesophageal echocardiographic windows. J Cardiothorac Vasc Anesth 2004;18:719–24
10. Richardson JS, Little MB. Functional tricuspid regurgitation in a patient with endocarditis. Anesth Analg 2009;109:1032–4
Back to Top | Article Outline

Teaching Points

  • Compared with the mitral or aortic valve, imaging the TV with TEE may be more difficult due to its relative distance from the transducer in ME views, a less favorable angle of interrogation, and shadowing from mitral annular calcification, prosthetic valves, or a lipomatous atrial septum.
  • The TV is the largest of the cardiac valves and adequate visualization requires a methodical approach using anteflexion, retroflexion, probe turning, and rotation of the imaging plane in multiple different views.
  • The TG short-axis view of the TV is the only 2D view to simultaneously image all three leaflets; the ME 4-chamber usually displays the septal and either anterior or posterior leaflets, depending on the degree of retroflexion. The ME RV inflow-outflow view displays the posterior and either anterior or septal leaflet, depending on the degree of probe anteflexion.

Supplemental Digital Content

Back to Top | Article Outline
© 2012 International Anesthesia Research Society