Echocardiographic evaluation of the tricuspid valve
- Nelson B Schiller, MD
Nelson B Schiller, MD
- Section Editor — Noninvasive Cardiac Imaging and Stress Testing
- Professor of Medicine, Anesthesia, and Radiology
- University of California, San Francisco
- Bryan Ristow, MD, FACC, FASE, FACP
Bryan Ristow, MD, FACC, FASE, FACP
- Associate Clinical Professor of Medicine
- University of California, San Francisco
- Xiushui Ren, MD
Xiushui Ren, MD
- Associate Research Director, Cardiology Fellowship
- California Pacific Medical Center
- Section Editors
- Warren J Manning, MD
Warren J Manning, MD
- Section Editor — Noninvasive Cardiac Imaging and Stress Testing
- Professor of Medicine and Radiology
- Harvard Medical School
- William H Gaasch, MD
William H Gaasch, MD
- Section Editor — Valvular Disease
- Professor of Medicine
- University of Massachusetts Medical School
- Tufts University School of Medicine
- Senior Consultant in Cardiology
- Lahey Clinic
Tricuspid valve disorders can be routinely identified and their severity can be 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) transthoracic echocardiography (TTE), the tricuspid valve is routinely recorded from the long (image 1) and short axis parasternal, apical four-chamber, and subcostal views. Overall, all tricuspid valve leaflets can be seen in less than 60 percent of patients with 2-D TTE from the subcostal window . The normal tricuspid leaflet thickness is <3 mm .
Identification of individual tricuspid valve 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 [1,3-5]:
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- ECHOCARDIOGRAPHY OF THE NORMAL TRICUSPID VALVE
- Transthoracic echocardiogram
- Transesophageal echocardiogram
- TRICUSPID STENOSIS
- Two-dimensional echocardiography
- Doppler echocardiography
- TRICUSPID REGURGITATION
- Summary of tricuspid regurgitation classification
- Two-dimensional echocardiography
- - Right ventricular size
- - Right ventricular function
- - Interventricular septum
- - Right atrial size
- - Right atrial volume changes
- - Interatrial septum
- - Tricuspid valve
- - Inferior vena cava
- Color-flow Doppler echocardiography
- - Comparison of color Doppler methods
- - Width of the vena contracta
- - Proximal flow acceleration
- - Color-flow jet size
- - Entrainment of the jet
- Pulse wave Doppler
- - Inferior vena caval flow
- - RV inflow
- Continuous wave Doppler
- - Shape of the jet
- - Density of the jet
- - Peak velocity of the jet
- Three-dimensional echocardiography
- Contrast echocardiography
- LESIONS CAUSING TRICUSPID REGURGITATION
- Functional tricuspid regurgitation
- - Atrial fibrillation
- - Pulmonary hypertension
- Left heart failure
- Primary tricuspid regurgitation
- - Rheumatic disease
- - Tricuspid valve prolapse
- - Ischemic tricuspid regurgitation
- - Endocarditis
- TTE or TEE?
- - Carcinoid tumors
- - Ebstein's anomaly
- - Trauma or mechanical interference
- SUMMARY AND RECOMMENDATIONS