Echo assessment of TVDr. Osama A. Bheleel

Cardiology departmentT.M.C

Introduction:The tricuspid valve complex consists of three leaflets(anterior, posterior, and septal), the chordae tendinae, two discrete papillary muscles, the fibrous tricuspid annulus, and the RA and RV myocardium. The anterior leaflet is the largest, The septal leaflet is the smallest and arises medially directly from thetricuspid annulus above the IVS.

TV annulus composed of septal and free wall parts.

The anterior and posterior attached to the free wall.

The anterior papillary muscle provides chordae to the anterior

and posterior leaflets, and the medial papillary muscle provides chordae to the posterior and septal leaflets.

Unlike the AV and MV it is not possible to visualize all TV leaflets simultaneously in one cross-sectional view by standard 2-D Echo either TTE or TEE due to the position of TV in the far field in relation to the probe.

Real-time three-dimensional echocardiography (RT3DE)can visualize the atrio-ventricular valves from both the ventricular and atrial side in detail without these limitations

2-D Echo of TV

Normal TV-leaflets visualized by RT 3D Echo from atrial (left) and ventricular side (right).

Native TV-Pathology

TV-StenosisAtiology:90% rheumaticIsolated TV CarcinoidCongenital very rareRare causesInfective endocarditisMetabolic/enzymatic abnormalitis

Rheumatic TV-stenosis seenfrom the RV.

Echo assessment of TV-Stenosis B-mode: reduction in leaflet mobility and dilated RA.

Doppler Echo:MPG <2mmHg normalMPG 2-6mmHgmoderate TSMPG>7mmHg severe TSPHT>190msec severe TS

TV regurgitation

Aetiology

Primary

CongenitalEbstein’s, AV canal

anomaly

AquiredPapilary muscle disfunction, IE,

Trauma

Secondary PAH, RV dilatation

Echo assessment of TRMorphologic ( B-mode): -prolapse -vegetation -Ebstein’s anomaly -carcinoid invlovement -right side chambers

enlargement -paradoxical septal

motion -dilation and systolic

pulsation of IVC

Doppler parameters

Color Doppler: to assess the jet area(>10cm2 indicates severe TR), and PISA radius (28cm/sec.) >9mm indicates also severe TR.

CW-doppler: dense jet with early peaking indicates severe TR.

Doppler of hepatic veins flow: systolic reversal of hepatic Doppler flow indicates severe TR.

Severe TRV wave cut-off sign

Hepatic vein flow

Infective Endocarditis:

Right sided IE common amongst IVDU

Large vegetation, various degree of TR.

Carcinoid:

Fibrous plaques termed as Carcinoid plaques.

usually present in the right side, occasionally in the left side.

Traumatic:

A complication of blunt chest trauma

Most frequently reported injury. chordal rupture, rupture of anterior pap. muscle and ant. Leaflet tear.

Iatrogenic TR:Iatrogenic injury from instrumentation eg. pacemaker wires frequent myocardial biopsies

Permanent PM have been identified as a risk factor for late TR by:

inhibition leaflet motion

perforation

scar tissue formation

Ebstein Anomaly:Apical displacement of both septal and posterior leaflets, exceeding 20mm

TR is moderate to severe

ASD mostly assocaited with Ebstein’s

25% have accessory pathway

3-DRT Echo of patient with Ebstein Anomaly,from atrial side.

Surgical treatment considerations of TRLowering of PAP following correction of left-sided

pathology does not slow down progression of mod-severe TR (irreversible pressure-induced RV remodelling)

TR annuloplasty should be contemplated when TR moderate-severe and accompanied by tricuspid annular dilatation (over 21 mm/m2)

residual and recurrent TR after annuloplasty is common (19% overall 8 yr recurrence)

Re-operation is rare b/c of high mortality risk (32% 30d mortality)

Carpentier-Edwards ring types appear better than non-ring annuloplasties (11% vs 22% 8 yr recurrence)

Percutaneous TV replacement:

(A)An 18-mm bovine jugular venous valve is mounted in the central part of the stent, with a PTFT membrane sutured to the ventricular disk.

(B)Percutaneous tricuspid valve implantation.

(C)Gross appearance of valve explanted at 1 month after implantation showing neoendocardial coverage of the stent (atrial view).

Prosthetic TV-pathology

Echo assessment of prostatic TV1-Imaging Considerations: assessing the position

of the valve and the movement of the cusps.

2-Doppler parameters: TV velocity varies with cycle length and inspiration, minimum 5 readings are needed to calculate the mean velocity and PG across the TV.

Measurements include peak E velocity, peak A velocity (for patients in SR), pressure half-time, mean gradient, and VTI.

Diagnosis of Prosthetic T.V Stenosis:

reduced opening of the mechanical occluder.

Indirect, nonspecific signs are an enlarged right atrium

and engorged inferior vena cava

CW Doppler parameteres of TV stenosis are:• E velocity > 1.7 m/s• mean gradient > 6 mm Hg• Pressure half-time > 230 ms.

Prosthetic TR:

RA and RV dilatation with diastolic septal flatteningoccurs in association with dilatation of the IVC andhepatic veins.

Echo doppler parameteres to assess the severity of TR are:

• Jet area by color doppler.• Vena contracta and PISA conversions. • Jet density and contour by CW Doppler.• Doppler systolic hepatic flow.

Severe

Abnormal or valve

dehiscence

>10

>0.7

Dense with early peaking

Holosystolic reversal

Markedly dilated

Moderate

Abnormal or valve

dehiscence

5-10

<0.7

Dense, variable contour

Blunted

Dilated

Mild

Usually normal

<5

Not defined

Incomplete or faint

Normal or blunted

Normal

Parameter

Valve structure

Jet area

VC width

Jet density

Doppler systolic

hepatic flow

RA, RV, IVC

Thank you

Mild

•Normal morphology•Normal RA/RV/IVC

•<5 cm² jet area•<5mm PISA radius

(28 cm/sec)•Soft parabolic TR

envelope•Systolic dominance

hepatic vein

Severe

•Flail/poor cooptation•RA/RV/IVC dilation

•>10 cm² jet area•>7mm VC (50 cm/sec)

•>9mm PISA radius (28 cm/sec)

•Dense triangular TR envelope

•Systolic reversal hepatic vein