Smarter Decisions,
Better Care

UpToDate synthesizes the most recent medical information into evidence-based practical recommendations clinicians trust to make the right point-of-care decisions.

  • Rigorous editorial process: Evidence-based treatment recommendations
  • World-Renowned physician authors: over 5,100 physician authors and editors around the globe
  • Innovative technology: integrates into the workflow; access from EMRs

Choose from the list below to learn more about subscriptions for a:


Subscribers log in here


Echocardiographic evaluation of the tricuspid valve

Topic Outline

GRAPHICS

INTRODUCTION

Tricuspid valve disorders can be routinely identified and their severity estimated by echocardiography. From a technical standpoint, transthoracic echocardiography (TTE) of the tricuspid valve is slightly more challenging than it is for left-sided valves. The location of the tricuspid valve as the most rightward valve places it at or just beneath the sternal edge and requires the ultrasound beam to be angled sharply rightward while maintaining transducer contact with the chest wall. Image quality from the apical and subcostal windows is limited by far field beam attenuation and dispersion.

Despite these impediments, the tricuspid valve can be adequately evaluated in most TTE examinations.

ECHOCARDIOGRAPHY OF THE NORMAL TRICUSPID VALVE

Anatomically, the tricuspid valve consists of anterior, septal and posterior leaflets. The anterior leaflet is the most anatomically constant echocardiographic feature, with the septal and posterior leaflets being variable in size and position.

Transthoracic echocardiogram — On two dimensional (2-D) TTE, the tricuspid valve is routinely recorded from the long (image 1) and short axis parasternal, apical four chamber, and subcostal views. The normal tricuspid valve thickness is <3 mm [1].

Identification of individual tricuspid leaflets in the 2-D views has been controversial. Data from pathologic examination, rotational 2-D tomograms, and 2-D reconstructions from three-dimensional (3-D) images have facilitated correct leaflet identification in 2-D views [2-4]:

                                          

Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Aug 2014. | This topic last updated: Aug 14, 2013.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2014 UpToDate, Inc.
References
Top
  1. Crawford MH, Roldan CA. Quantitative assessment of valve thickness in normal subjects by transesophageal echocardiography. Am J Cardiol 2001; 87:1419.
  2. Tajik AJ, Seward JB, Hagler DJ, et al. Two-dimensional real-time ultrasonic imaging of the heart and great vessels. Technique, image orientation, structure identification, and validation. Mayo Clin Proc 1978; 53:271.
  3. Brown AK, Anderson V. Two dimensional echocardiography and the tricuspid valve. Leaflet definition and prolapse. Br Heart J 1983; 49:495.
  4. Anwar AM, Geleijnse ML, Soliman OI, et al. Assessment of normal tricuspid valve anatomy in adults by real-time three-dimensional echocardiography. Int J Cardiovasc Imaging 2007; 23:717.
  5. Tei C, Shah PM, Cherian G, et al. Echocardiographic evaluation of normal and prolapsed tricuspid valve leaflets. Am J Cardiol 1983; 52:796.
  6. Otto C. Textbook of clinical echocardiography, 3rd ed, Elsevier Saunders, 2004.
  7. Feigenbaum H. Feigenbaum's Echocardiography, 6th ed, Lippincott, Williams & Wilkins, Philadelphia 2005.
  8. Pothineni KR, Duncan K, Yelamanchili P, et al. Live/real time three-dimensional transthoracic echocardiographic assessment of tricuspid valve pathology: incremental value over the two-dimensional technique. Echocardiography 2007; 24:541.
  9. Zaroff JG, Picard MH. Transesophageal echocardiographic (TEE) evaluation of the mitral and tricuspid valves. Cardiol Clin 2000; 18:731.
  10. Cheitlin MD, Armstrong WF, Aurigemma GP, et al. ACC/AHA/ASE 2003 guideline update for the clinical application of echocardiography: summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/ASE Committee to Update the 1997 Guidelines for the Clinical Application of Echocardiography). Circulation 2003; 108:1146.
  11. Pérez JE, Ludbrook PA, Ahumada GG. Usefulness of Doppler echocardiography in detecting tricuspid valve stenosis. Am J Cardiol 1985; 55:601.
  12. Fawzy ME, Mercer EN, Dunn B, et al. Doppler echocardiography in the evaluation of tricuspid stenosis. Eur Heart J 1989; 10:985.
  13. Schiller NB. Pulmonary artery pressure estimation by Doppler and two-dimensional echocardiography. Cardiol Clin 1990; 8:277.
  14. Badano LP, Muraru D, Enriquez-Sarano M. Assessment of functional tricuspid regurgitation. Eur Heart J 2013; 34:1875.
  15. Isaaz K, Munoz del Romeral L, Lee E, Schiller NB. Quantitation of the motion of the cardiac base in normal subjects by Doppler echocardiography. J Am Soc Echocardiogr 1993; 6:166.
  16. Simonson JS, Schiller NB. Descent of the base of the left ventricle: an echocardiographic index of left ventricular function. J Am Soc Echocardiogr 1989; 2:25.
  17. Zoghbi WA, Enriquez-Sarano M, Foster E, et al. Recommendations for evaluation of the severity of native valvular regurgitation with two-dimensional and Doppler echocardiography. J Am Soc Echocardiogr 2003; 16:777.
  18. Kusumoto FM, Muhiudeen IA, Kuecherer HF, et al. Response of the interatrial septum to transatrial pressure gradients and its potential for predicting pulmonary capillary wedge pressure: an intraoperative study using transesophageal echocardiography in patients during mechanical ventilation. J Am Coll Cardiol 1993; 21:721.
  19. Sagie A, Schwammenthal E, Padial LR, et al. Determinants of functional tricuspid regurgitation in incomplete tricuspid valve closure: Doppler color flow study of 109 patients. J Am Coll Cardiol 1994; 24:446.
  20. Tuñon J, Cordoba M, Rey M, et al. Assessment of chronic tricuspid regurgitation by colour Doppler echocardiography: a comparison with angiography in the catheterization room. Eur Heart J 1994; 15:1074.
  21. Gonzalez-Vilchez F, Zarauza J, Vazquez de Prada JA, et al. Assessment of tricuspid regurgitation by Doppler color flow imaging: angiographic correlation. Int J Cardiol 1994; 44:275.
  22. Grossmann G, Stein M, Kochs M, et al. Comparison of the proximal flow convergence method and the jet area method for the assessment of the severity of tricuspid regurgitation. Eur Heart J 1998; 19:652.
  23. Shapira Y, Porter A, Wurzel M, et al. Evaluation of tricuspid regurgitation severity: echocardiographic and clinical correlation. J Am Soc Echocardiogr 1998; 11:652.
  24. Utsunomiya T, Doshi R, Patel D, et al. Regurgitant volume estimation in patients with mitral regurgitation: initial studies using color Doppler "proximal isovelocity surface area" method. Echocardiography 1992; 9:63.
  25. Simpson IA, Shiota T, Gharib M, Sahn DJ. Current status of flow convergence for clinical applications: is it a leaning tower of "PISA"? J Am Coll Cardiol 1996; 27:504.
  26. Tribouilloy CM, Enriquez-Sarano M, Capps MA, et al. Contrasting effect of similar effective regurgitant orifice area in mitral and tricuspid regurgitation: a quantitative Doppler echocardiographic study. J Am Soc Echocardiogr 2002; 15:958.
  27. Tribouilloy CM, Enriquez-Sarano M, Bailey KR, et al. Quantification of tricuspid regurgitation by measuring the width of the vena contracta with Doppler color flow imaging: a clinical study. J Am Coll Cardiol 2000; 36:472.
  28. Bonow RO, Carabello BA, Chatterjee K, et al. 2008 Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation 2008; 118:e523.
  29. Danicek V, Sagie A, Vaturi M, et al. Relation of tricuspid inflow E-wave peak velocity to severity of tricuspid regurgitation. Am J Cardiol 2006; 98:399.
  30. Thomas L, Foster E, Schiller NB. Peak mitral inflow velocity predicts mitral regurgitation severity. J Am Coll Cardiol 1998; 31:174.
  31. Skjaerpe T, Hatle L. Diagnosis of tricuspid regurgitation. Sensitivity of Doppler ultrasound compared with contrast echocardiography. Eur Heart J 1985; 6:429.
  32. Sakai K, Nakamura K, Satomi G, et al. Evaluation of tricuspid regurgitation by blood flow pattern in the hepatic vein using pulsed Doppler technique. Am Heart J 1984; 108:516.
  33. Imanishi T, Nakatani S, Yamada S, et al. Validation of continuous wave Doppler-determined right ventricular peak positive and negative dP/dt: effect of right atrial pressure on measurement. J Am Coll Cardiol 1994; 23:1638.
  34. Enriquez-Sarano M, Kaneshige AM, Tajik AJ, et al. Amplitude-weighted mean velocity: clinical utilization for quantitation of mitral regurgitation. J Am Coll Cardiol 1993; 22:1684.
  35. Yock PG, Popp RL. Noninvasive estimation of right ventricular systolic pressure by Doppler ultrasound in patients with tricuspid regurgitation. Circulation 1984; 70:657.
  36. Douglas PS, Khandheria B, Stainback RF, et al. ACCF/ASE/ACEP/ASNC/SCAI/SCCT/SCMR 2007 appropriateness criteria for transthoracic and transesophageal echocardiography: a report of the American College of Cardiology Foundation Quality Strategic Directions Committee Appropriateness Criteria Working Group, American Society of Echocardiography, American College of Emergency Physicians, American Society of Nuclear Cardiology, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, and the Society for Cardiovascular Magnetic Resonance endorsed by the American College of Chest Physicians and the Society of Critical Care Medicine. J Am Coll Cardiol 2007; 50:187.
  37. Hinderliter AL, Willis PW 4th, Long WA, et al. Frequency and severity of tricuspid regurgitation determined by Doppler echocardiography in primary pulmonary hypertension. Am J Cardiol 2003; 91:1033.
  38. Waller BF, Moriarty AT, Eble JN, et al. Etiology of pure tricuspid regurgitation based on anular circumference and leaflet area: analysis of 45 necropsy patients with clinical and morphologic evidence of pure tricuspid regurgitation. J Am Coll Cardiol 1986; 7:1063.
  39. Winslow TM, Redberg RF, Foster E, Schiller NB. Transesophageal echocardiographic detection of abnormalities of the tricuspid valve in adults associated with spontaneous closure of perimembranous ventricular septal defect. Am J Cardiol 1992; 70:967.
  40. Kai H, Koyanagi S, Hirooka Y, et al. Right-to-left shunt across atrial septal defect related to tricuspid regurgitation: assessment by transesophageal Doppler echocardiography. Am Heart J 1994; 127:578.
  41. Hansing CE, Rowe GG. Tricuspid insufficiency. A study of hemodynamics and pathogenesis. Circulation 1972; 45:793.
  42. Najib MQ, Vinales KL, Vittala SS, et al. Predictors for the development of severe tricuspid regurgitation with anatomically normal valve in patients with atrial fibrillation. Echocardiography 2012; 29:140.
  43. Goswami KC, Rao MB, Dev V, Shrivastava S. Juvenile tricuspid stenosis and rheumatic tricuspid valve disease: an echocardiographic study. Int J Cardiol 1999; 72:83.
  44. Hannoush H, Fawzy ME, Stefadouros M, et al. Regression of significant tricuspid regurgitation after mitral balloon valvotomy for severe mitral stenosis. Am Heart J 2004; 148:865.
  45. Werner JA, Schiller NB, Prasquier R. Occurrence and significance of echocardiographically demonstrated tricuspid valve prolapse. Am Heart J 1978; 96:180.
  46. Ton-Nu TT, Levine RA, Handschumacher MD, et al. Geometric determinants of functional tricuspid regurgitation: insights from 3-dimensional echocardiography. Circulation 2006; 114:143.
  47. Lewen MK, Bryg RJ, Miller LW, et al. Tricuspid regurgitation by Doppler echocardiography after orthotopic cardiac transplantation. Am J Cardiol 1987; 59:1371.
  48. Chandraratna PA, Aronow WS. Spectrum of echocardiographic findings in tricuspid valve endocarditis. Br Heart J 1979; 42:528.
  49. San Román JA, Vilacosta I, Zamorano JL, et al. Transesophageal echocardiography in right-sided endocarditis. J Am Coll Cardiol 1993; 21:1226.
  50. Reynolds HR, Jagen MA, Tunick PA, Kronzon I. Sensitivity of transthoracic versus transesophageal echocardiography for the detection of native valve vegetations in the modern era. J Am Soc Echocardiogr 2003; 16:67.
  51. Cohen GI, Klein AL, Chan KL, et al. Transesophageal echocardiographic diagnosis of right-sided cardiac masses in patients with central lines. Am J Cardiol 1992; 70:925.
  52. Himelman RB, Schiller NB. Clinical and echocardiographic comparison of patients with the carcinoid syndrome with and without carcinoid heart disease. Am J Cardiol 1989; 63:347.
  53. Edwards WD. Embryology and pathologic features of Ebstein's anomaly. Prog Pediatr Cardiol 1993;2:5.
  54. Shiina A, Seward JB, Tajik AJ, et al. Two-dimensional echocardiographic--surgical correlation in Ebstein's anomaly: preoperative determination of patients requiring tricuspid valve plication vs replacement. Circulation 1983; 68:534.
  55. Ports TA, Silverman NH, Schiller NB. Two-dimensional echocardiographic assessment of Ebstein's anomaly. Circulation 1978; 58:336.
  56. Hausen B, Albes JM, Rohde R, et al. Tricuspid valve regurgitation attributable to endomyocardial biopsies and rejection in heart transplantation. Ann Thorac Surg 1995; 59:1134.
  57. Reddy SC, Rath GA, Ziady GM, et al. Tricuspid flail leaflets after orthotopic heart transplant: a new complication of endomyocardial biopsy. J Am Soc Echocardiogr 1993; 6:223.
  58. Nguyen V, Cantarovich M, Cecere R, Giannetti N. Tricuspid regurgitation after cardiac transplantation: how many biopsies are too many? J Heart Lung Transplant 2005; 24:S227.
  59. Bonmassari R, Nicolosi GL, Disertori M. [Tricuspid insufficiency with rupture of the chordae tendineae caused by closed thoracic trauma: evaluation by transesophageal echocardiography. Description of a case]. G Ital Cardiol 1994; 24:763.
  60. Tatebe S, Uehara A, Shinonaga M, Kuraoka S. Posttraumatic tricuspid insufficiency successfully repaired by conventional technique. J Card Surg 2005; 20:356.