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Notch of the Anterior Leaflet of the Tricuspid Valve with Severe Tricuspid Regurgitation

Kuroda, Masataka MD, PhD; Ohta, Joe MD; Mita, Norikatsu MD; Miyoshi, Sohtaro MD, PhD; Kadoi, Yuji MD, PhD; Saito, Shigeru MD, PhD

doi: 10.1213/ANE.0000000000000570
Cardiovascular Anesthesiology: Echo Rounds
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From the *Department of Anesthesiology, Gunma University Graduate School of Medicine, Maebashi, Japan; and Department of Anesthesiology, Saitama Prefectural Cardiovascular and Respiratory Center, Kumagaya, Japan.

Accepted for publication September 11, 2014.

Funding: None.

The authors declare no conflicts of interest.

Written informed consent was obtained from the patient for publication of this case report and all accompanying images.

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.

Reprints will not be available from the authors.

Address correspondence to Masataka Kuroda, MD, PhD, Department of Anesthesiology, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi 371–8511, Japan. Address e-mail to m.kurohyou@gmail.com.

A 70-year-old man was scheduled for tricuspid valvuloplasty for severe tricuspid regurgitation (TR).   Preoperative 2D transthoracic echocardiography revealed severe TR resulting from tricuspid annular dilation with a thickened anterior tricuspid leaflet (AL).

Intraoperative transesophageal echocardiography (TEE) was performed using a 3D echocardiographic matrix-array probe (X7-2t Transducer; Philips Healthcare, Andover, MA). The midesophageal (ME) 4-chamber view demonstrated a dilated right ventricle (RV), dilated tricuspid annular dimension of 44 mm at end diastole, and discontinuity in the AL (Fig. 1A and the first part of Video 1, Supplemental Digital Content, http://links.lww.com/AA/B42). Color-flow Doppler (CFD) analysis revealed a central, broad-based jet of TR (second part of Video 1, Supplemental Digital Content, http://links.lww.com/AA/B42). The ME RV inflow view with the multiplane angle at 70 degrees demonstrated a thickened and divided tricuspid AL, with each bundle of chordae from the anterior papillary muscle (Fig. 1B and the third part of Video 1, Supplemental Digital Content, http://links.lww.com/AA/B42). CFD revealed severe TR (fourth part of Video 1, Supplemental Digital Content, http://links.lww.com/AA/B42). The transgastric RV basal short-axis view demonstrated a notch at the center of the AL (Fig. 1C and the first part of Video 2, Supplemental Digital Content, http://links.lww.com/AA/B43), and CFD analysis revealed the location of the TR (second part of Video 2, Supplemental Digital Content, http://links.lww.com/AA/B43). Next, a 3D echocardiographic view was scanned for additional morphological evaluations. A 3D zoom image was obtained from an ME view of the tricuspid valve at 100 degrees and manipulated to provide en face views of the tricuspid valve from the right atrium (RA) with the septal leaflet located in the 6 o’clock position, which confirms the spatial relationship of the AL to surrounding tissues such as the aortic valve and anterior mitral leaflet1 (Fig. 2A, and the first part of Video 3, Supplemental Digital Content, http://links.lww.com/AA/B44). This view revealed that the notch in the tricuspid AL did not extend to the annulus. To facilitate analysis and understanding of the 2D ME views in Figure 1, A and B, 2 lines were depicted on the 3D view obtained with a 90-degree clockwise rotation from the RA view in Figure 2, A and B. Three-dimensional morphological and CFD analysis from the RV side demonstrated the location and extent of the notch and the site of the regurgitation (second and third parts of Video 3, Supplemental Digital Content, http://links.lww.com/AA/B44). Surgical inspection was consistent with the 3D view from the RA perspective at mid-diastole (Fig. 3, A and B) and confirmed that the defect was not a cleft but a notch. Although echo dropout was present in the 3D view, the notch could be identified and correlated with 2D imaging (Fig. 3B).

Figure 1

Figure 1

Figure 2

Figure 2

Figure 3

Figure 3

The notch was sutured, and an annuloplasty ring was implanted for correction of the dilated annulus. Only trivial residual TR was observed on TEE after weaning off cardiopulmonary bypass. The postoperative course of the patient was uneventful.

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DISCUSSION

Isolated congenital TR is very rare, and one of its typical causes includes a cleft tricuspid valve.2 A review of 28,091 echocardiograms in the general population during a period of 7 years reported an incidence of cleft tricuspid valve of 0.018%, whereas Eichhorn et al.3 found a higher incidence of this anomaly in 0.6% of patients with associated congenital diseases.

Generally, a cleft leaflet is defined as a discontinuity in the leaflet that extends to the annulus, whereas a notch is a discontinuity that does not extend to the annulus.1 Tricuspid notches are commonly noted during surgical inspection or pathologic examination although they are less frequently recognized by echocardiography. Silver et al.4 found that many notches, of variable depth and width, were observed in the free edge of the tricuspid AL, close to the anteroseptal commissure in 47 of 50 leaflets, whereas another notch was seen at the apex of the AL in 6 of 50 hearts, which, although not as deep as a commissure, subdivided the leaflet, and rough zone chordae were always inserted into them. The notch in our patient would be consistent with the latter. Unlike leaflet clefts, it is unclear how frequently notches contribute to TR.

The use of 2D and 3D TEE for assessment of mitral valve leaflet clefts has been reported5,6; we applied a similar technique to evaluate the tricuspid valve. The 2D transgastric RV basal short-axis view enables visualization of en face views of the tricuspid valve, but it is neither always able to scan the precise location and range of extension of the abnormal notch nor can it display the regurgitant orifice with CFD because the imaging plane interrogates the leaflets obliquely and because there might be echo dropout due to annular calcification or the presence of a pulmonary artery catheter, especially in the tricuspid valve area. However, 3D echocardiographic analysis from the RA side enables scanning of the precise morphology of the notched leaflet. Ultrasound insertion into the whole tricuspid leaflet and annulus from above, together with volume scanning, allows demonstration of the entire structure of the leaflet notch and depicts the precise location and extension to the annulus although the quality of the scan may not be equal to that of the mitral valve because the tricuspid valve is more distant from the TEE transducer, and there could be echo dropout because of the thinner leaflet.

In our case, 3D analysis enabled visualization of true en face views of the tricuspid valve leaflet and annulus and confirmed that the notch did not extend to the annulus, but was as deep as a commissure, leading to the diagnosis of a notch rather than a cleft on the AL. The ME RV inflow view allowed orthogonal scanning of the notched AL and the major axis of the regurgitant jet with CFD, indicating the location of the TR and its cause, which was consistent with 3D CFD analysis. Furthermore, the pathophysiology of TR in this case included coaptation failure because of complex mechanisms of thickened anterior leaflet tips at the notch and a laterally dilated annulus. Thickening of the AL compared with the septal and posterior leaflets was more clearly and precisely depicted in 2D analysis of the ME 4-chamber and RV inflow views in this case. However, 3D analysis with en face views of the tricuspid valve was useful for evaluating the location and extent of the notch, the precise location of the regurgitant orifice, and morphologic images of the laterally dilated annulus. This information enabled planning of the surgical procedure of tricuspid valvuloplasty.

In conclusion, detailed 2D and 3D TEE analysis complement each other in analyzing the morphological features of tricuspid valve notches and the pathophysiology of TR. CFD analysis with both 2D and 3D TEE is useful for diagnosing the precise origin of TR.

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Clinician’s Key Teaching Points

By J. Skubas, MD, Roman M. Sniecinski, MD, and Martin J. London, MD

  • Isolated congenital tricuspid valve (TV) regurgitation, although rare, is often the result of a cleft in 1 of the 3 leaflets. A cleft is defined as an anatomic discontinuity that extends through the body of the leaflet (“clear zone”) to the annulus. A more limited form of discontinuity, often called a “notch,” does not extend all the way to the annulus.
  • Two-dimensional transesophageal echocardiography (TEE) imaging in the midesophageal (ME) 4-chamber or right ventricular inflow–outflow views usually allows assessment of the mobility and quality of the TV leaflets but often fails to distinguish between clefts and notches. Three-dimensional TEE imaging, by providing a true en face view, facilitates more precise identification and localization of leaflet discontinuities.
  • In this case of isolated severe tricuspid regurgitation, 2D TEE imaging revealed a dilated tricuspid annulus and a thickened and divided anterior TV leaflet. Using 3D TEE datasets, acquired from a modified ME bicaval view and rotated to match the 2D ME orientation from the right atrial and right ventricular perspectives, the extent of the anterior leaflet discontinuity was correctly diagnosed as a notch.
  • Two-dimensional TEE oblique echocardiographic planes do not always permit the correct diagnosis of a TV leaflet anatomic lesion or the precise location of tricuspid regurgitation jets. This may be important in cases of concurrent mitral valve regurgitation, when the TV pathology should be considered when planning for surgery. Three-dimensional TEE greatly facilitates identification of subtle leaflet discontinuities such as TV clefts and notches.
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DISCLOSURES

Name: Masataka Kuroda, MD, PhD.

Contribution: This author helped design the study, conduct the study, data collection, data analysis, and manuscript preparation.

Attestation: Masataka Kuroda approved the final manuscript.

Name: Joe Ohta, MD.

Contribution: This author helped prepare the manuscript.

Attestation: Joe Ohta approved the final manuscript.

Name: Norikatsu Mita, MD.

Contribution: This author helped prepare the manuscript.

Attestation: Norikatsu Mita approved the final manuscript.

Name: Sohtaro Miyoshi, MD, PhD.

Contribution: This author helped prepare the manuscript.

Attestation: Sohtaro Miyoshi approved the final manuscript.

Name: Yuji Kadoi, MD, PhD.

Contribution: This author helped prepare the manuscript.

Attestation: Yuji Kadoi approved the final manuscript.

Name: Shigeru Saito, MD, PhD.

Contribution: This author helped prepare the manuscript.

Attestation: Shigeru Saito approved the final manuscript.

This manuscript was handled by: Martin J. London, MD.

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REFERENCES

1. Lang RM, Badano LP, Tsang W, Adams DH, Agricola E, Buck T, Faletra FF, Franke A, Hung J, de Isla LP, Kamp O, Kasprzak JD, Lancellotti P, Marwick TH, McCulloch ML, Monaghan MJ, Nihoyannopoulos P, Pandian NG, Pellikka PA, Pepi M, Roberson DA, Shernan SK, Shirali GS, Sugeng L, Ten Cate FJ, Vannan MA, Zamorano JL, Zoghbi WAAmerican Society of Echocardiography; European Association of Echocardiography. . EAE/ASE recommendations for image acquisition and display using three-dimensional echocardiography. J Am Soc Echocardiogr. 2012;25:3–46
2. Motoyoshi N, Tofukuji M, Sakurai M, Ohmi M, Tabayashi K. Cleft on tricuspid anterior leaflet. Ann Thorac Surg. 2001;71:1350–1
3. Eichhorn P, Ritter M, Suetsch G, von Segesser LK, Turina M, Jenni R. Congenital cleft of the anterior tricuspid leaflet with severe tricuspid regurgitation in adults. J Am Coll Cardiol. 1992;20:1175–9
4. Silver MD, Lam JH, Ranganathan N, Wigle ED. Morphology of the human tricuspid valve. Circulation. 1971;43:333–48
5. Townsley MM, Chen EP, Sniecinski RM. Cleft posterior mitral valve leaflet: identification using three-dimensional transesophageal echocardiography. Anesth Analg. 2010;111:1366–8
6. Cheng HL, Huang CH, Tsai HE, Chen MY, Fan SZ, Hsiao PN. Intraoperative assessment of partial atrioventricular septal defect with a cleft mitral valve by real-time three-dimensional transesophageal echocardiography. Anesth Analg. 2012;114:731–4

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