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.
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.
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.
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
- 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.