Right-sided valve disease







TABLE 6-1

Best Views for Assessing Tricuspid Valve
























ME four-chamber view With probe anteflexed, septal leaflet will be seen adjacent to interventricular septum, and anterior leaflet adjacent to right ventricular free wall. Retroflexion will allow visualization of posterior leaflet adjacent to free wall.
ME RV inflow–outflow view With transducer angle rotated to about 50–80 degrees, anterior leaflet and posterior leaflet are seen.
TG views Transgastric short-axis view of tricuspid valve with all three leaflets can be seen with transducer angle rotated to approximately 0–30 degrees.
Transgastric long-axis view at 90–120 degrees with probe rotated to patient’s right shows anterior and posterior leaflets. Advancing and flexing probe allows visualization pulmonic in addition to tricuspid valves.
3D echocardiography Obtain view of tricuspid valve from 0–30 degrees midesophageal, four-chamber view tilted so that the valve is centered in imaging plane, or transgastric view with anteflexion.
Acquire using narrow-angle, single-beat mode.
Guidelines indicate that TTE may be preferable to TEE for 3D of tricuspid valve.


TABLE 6-2

Best Views for Assessing Pulmonic Valve



























ME RV inflow–outflow view With transducer angle rotated to about 50–80 degrees from midesophageal four-chamber view, two leaflets of pulmonic valve are seen anterior to aortic valve.
High esophageal views Image descending aorta in midesophageal longitudinal plane (approximately 70–110 degrees).
Withdraw probe to level of aortic arch.
Rotate probe clockwise to image pulmonic valve and RVOT. Rotating transducer position back to approximately 0 degrees, and adjustment of transducer depth and flexion allows pulmonary valve, main PA, and its bifurcation to be seen.
TG views Transgastric long-axis view at 90–120 degrees with probe rotated to patient’s right shows anterior and posterior leaflets of tricuspid valve. Advancing and flexing probe allows visualization of pulmonic in addition to tricuspid valves.
3D echocardiography Obtain view of pulmonic valve from either 90-degree, high-esophageal, or 120-degree, midesophageal three-chamber view rotated to center pulmonic valve.
Acquire using narrow-angle, single-beat mode.
Guidelines indicate that TTE may be preferable to TEE for 3D of pulmonic valve.


Normal tricuspid and pulmonic valves


CASE 6-1


Normal tricuspid and pulmonic valves



Fig 6.1


Left panel shows three leaflets of tricuspid valve at time of surgery, with normal leaflets appearing thin, smooth, and with complete coaptation in systole. In the center panel, the corresponding 3D TEE image is seen from right atrial aspect. Video clip shows both right atrial (left) and right ventricular (right) aspects of valve. Right panel shows exposure of tricuspid valve after right atriotomy. Approximate position of AVN is displayed. It is susceptible to injury during procedures on tricuspid valve.

(Reproduced with permission from Elsevier Limited, Kidlington, Oxford, UK.) Ao = aorta; CS = coronary sinus; IVC = inferior vena cava; PA = pulmonary artery; AVN = atrio-ventricular node; S, A, P = septal, anterior, and posterior leaflets of tricuspid valve; SVC = superior vena cava. (Right panel used with permission of Elsevier.)



Fig 6.2


With probe in midesophageal position and anteflexed, four-chamber view (right panel) shows anterior and septal leaflets. At 60 degrees, anterior and posterior leaflets are seen.



Fig 6.3


The use of 3D echocardiography allows definitive identification of the tricuspid leaflets. In two top panels, with probe anteflexed, green plane is seen to intersect anterior and septal leaflets; in bottom two panels, with probe retroflexed, green plane is seen to intersect posterior and septal leaflets.



Fig 6.4


From transgastric position, tricuspid valve is imaged in short axis at 30 degrees, demonstrating all three leaflets.



Fig 6.5


From transgastric view, right ventricular inflow view is obtained by starting in short-axis view of left ventricle, rotating image plane to about 120 degrees, and turning transducer slightly to patient’s right. Posterior and anterior tricuspid valve leaflets are seen. Proximal outflow tract is also frequently seen and slight advancement of probe may allow imaging and Doppler interrogation of pulmonic valve.



Fig 6.6


This view of pulmonic valve and right ventricular outflow tract (left panel) was acquired from very high esophageal position. In right panel, comparable 3D image is seen.



Fig 6.7


Steps to image pulmonic valve and RV outflow tract from high esophageal position. 1. Image descending aorta in long axis, then slowly withdraw probe making small rotational adjustments to keep aorta centered. 2. As arch is approached it will be imaged in short axis. Begin rotating probe to patient’s right. Left pulmonary artery will come into view. 3. Continue rotating probe until main pulmonary artery, pulmonic valve (arrow), and RV outflow tract come into view. (3D animation was reproduced with permission from TEE Simulation on Virtual TEE website at http://pie.med.utoronto.ca/TEE. )



Fig 6.8


In left panel at midesophageal position, image plane is rotated to about 50 to 80 degrees from four-chamber view to obtain “inflow–outflow” view of RV. Orthogonal view of pulmonic valve in middle panel shows three leaflets of pulmonic valve. Right panel shows comparable 3D image.



Fig 6.9


By moving transducer to position just on gastric side of gastroesophageal junction, view of both tricuspid and pulmonic valves (shown in diastole on left and in systole on right ) can be obtained. Note that this image plane is same as shown in Fig 6.8 , rotated 90 degrees counterclockwise, due to different position of transducer in transgastric compared with midesophageal position. Arrow points to central venous catheter in superior vena cava.




Comments


The tricuspid valve is routinely evaluated on TEE in at least two views. Most often the four-chamber view and short-axis (“inflow–outflow”) view are used, with 2D imaging of leaflet thickness and mobility and annulus size with color Doppler evaluation of regurgitation. When regurgitation is present, severity is evaluated based on the vena contracta width. In addition, velocity is recorded using continuous wave Doppler, although velocity may be underestimated, as it is not always possible to obtain parallel intercept angle between the ultrasound beam and direction of the tricuspid regurgitant jet on TEE examination. Additional views of the tricuspid valve are typically obtained only if initial images are abnormal or if there is clinical concern for tricuspid valve involvement, such as a patient with suspected endocarditis. 3D imaging, either on TEE or TTE imaging, may be helpful in assuring correct identification of the three valve leaflets ( Fig 6.3 ).


The pulmonic valve is routinely evaluated in long-axis view from the midesophageal inflow–outflow view ( Fig 6.8 ). When indicated, the pulmonic valve and RV outflow tract may be imaged from the high esophageal position ( Fig 6.7 ) or the transgastric position ( Fig 6.9 ).




Rheumatic heart disease


CASE 6-2


Rheumatic mixed tricuspid disease associated with mitral stenosis


This 36-year-old woman had long history of valvular heart disease secondary to rheumatic fever. She had suffered a stroke 15 years before admission, thought to be embolic in nature, and was started on warfarin. She now presented with increasing fatigue and shortness of breath, and clinical evidence of congestive heart failure.



Fig 6.10


Chest radiography revealed global cardiomegaly and central pulmonary congestion.



Fig 6.11


In TEE four-chamber plane at 0-degree rotation, zoom image of tricuspid valve in systole reveals significant leaflet thickening. Color Doppler flow imaging demonstrates moderate tricuspid regurgitation with vena contracta width of 4 mm. There is coexistent mitral stenosis, with spontaneous contrast visible in enlarged left atrium.



Fig 6.12


In same image plane as Fig 6.11 , diastolic image shows doming of tricuspid leaflets, consistent with rheumatic disease, with narrow antegrade flow stream suggesting tricuspid stenosis.



Fig 6.13


With probe now rotated to 120 degrees, diastolic doming (sometimes called “hockey stick shape”) of anterior mitral leaflet is typical for rheumatic valve disease. Interventricular septum bows toward LV during systole and diastole so that LV appears “ D ”-shaped in short-axis view (see video), characteristic of RV pressure overload.



Fig 6.14


With probe now advanced to transgastric position and rotated to 70 degrees, pulsed wave Doppler of hepatic vein demonstrates systolic flow reversal (arrow), which is typical of severe tricuspid regurgitation. However, this finding is only specific for severe tricuspid regurgitation when normal sinus rhythm is present. In this patient, there is no P wave on ECG or a-velocity on Doppler because patient is in atrial fibrillation. Thus this finding is consistent with other findings suggesting moderate tricuspid regurgitation.



Fig 6.15


From apical transgastric transducer position, continuous-wave Doppler of tricuspid inflow demonstrates mean gradient of 3.4 mm Hg, and pressure half-time of 180 msec, consistent with mild tricuspid stenosis. Density of systolic signal of tricuspid regurgitation is less dense than antegrade flow, consistent with moderate tricuspid regurgitation. Velocity of tricuspid regurgitation jet is 3.4 m/sec, consistent with RV to RA peak systolic gradient of 46 mm Hg. Added to central venous pressure of 15 mm Hg yields estimated RV systolic pressure of 61 mm Hg.



Fig 6.16


At surgery, three leaflets of tricuspid valve are seen; they are all severely thickened, with fusion of all three commissures (arrows), which is pathognomonic for rheumatic valve disease.



Fig 6.17


Postoperatively in four-chamber view, two posts of prosthetic tricuspid valve are seen (arrows). In right frame, color Doppler shows only mild tricuspid regurgitation.



Fig 6.18


From the atrial perspective, 3D TEE allows enface visualization of tissue tricuspid prosthesis, as well as bileaflet mechanical prosthesis in mitral position.



Fig 6.19


Surgical view with right atrium still open shows trileaflet tissue prosthesis in tricuspid valve position.




Comments


The tricuspid valve is affected by the rheumatic process in about 5% to 10% of patients with rheumatic mitral valve disease. Rheumatic involvement of the tricuspid valve results in leaflet thickening, commissural fusion, and fusion and shortening of the chords, although findings are often subtle compared with the mitral valve. Rheumatic involvement of the tricuspid valve can cause stenosis, due to commissural fusion, or regurgitation, due to chordal shortening and fusion, but severe stenosis is uncommon. Most often, there is a combination of stenosis and regurgitation, which may result in symptoms even when either lesion, in isolation, might not be considered severe. With left-sided rheumatic mitral valve disease, intervention for tricuspid involvement or severe annular dilation is recommended with any degree of valve dysfunction because progressive tricuspid disease often occurs late after surgery for rheumatic mitral valve disease.


Suggested reading




  • 1.

    Lin G, Bruce CJ, Connolly HM: Diseases of the tricuspid and pulmonic valves. In Otto CM, Bonow RO, editors: Valvular heart disease, ed 4, Philadelphia, 2014, Elsevier, pp 375–395.



CASE 6-3


Rheumatic tricuspid regurgitation in patient with bioprosthetic aortic valve


A 28-year-old man presented with 2-month history of increasing dyspnea on exertion and leg edema. Past medical history was notable for bioprosthetic aortic valve replacement 10 years previously for severe symptomatic aortic regurgitation. Echocardiography revealed prosthetic aortic valve stenosis and regurgitation, as well as anatomic changes consistent with rheumatic mitral and tricuspid valve disease with mixed stenosis/regurgitation of both atrioventricular valves. There was severe LV dilation with normal systolic function.


Right heart catheterization revealed an RA mean pressure 8 mm Hg, RV pressure of 46/6 mm Hg, PA pressure of 46/23 mm Hg with mean of 30 mm Hg, wedge pressure of 17 mm Hg, transpulmonary gradient of 13 mm Hg, pulmonary vascular resistance (Fick) of 4.5 wood units, and systemic vascular resistance (Fick) of 1384 dsc-5.


Surgical intervention was recommended for symptomatic prosthetic valve dysfunction and concurrent rheumatic mitral valve disease. After mitral and aortic valve replacements were performed, attention was turned to the tricuspid valve. An attempt at valve repair was unsuccessful so the tricuspid valve was replaced with bioprosthetic valve.



Fig 6.20


In midesophageal four-chamber view, two leaflets most likely visualized are septal and anterior, as probe is anteflexed. During systole jet of tricuspid regurgitation (arrow) is seen with vena contract width of 8 mm. During diastole, restricted leaflet motion with diastolic doming and relatively immobility of septal leaflet is seen.



Fig 6.21


Continuous-wave Doppler shows diastolic mean gradient of 10 mm Hg, consistent with high transvalvular flow rate, most likely due to tricuspid regurgitation. Measurement of pressure half-time is challenging in this patient because short diastolic filling period (rapid heart rate) and superimposed atrial velocity obscure early diastolic deceleration slope. However, slope appears consistent with only mild to moderate tricuspid stenosis.



Fig 6.22


Vena contracta of tricuspid regurgitant jet is measured at 8 mm using zoom mode to show narrow neck between region of flow acceleration on RV size of valve and turbulence jet in RA. Holo-systolic flow reversal is present in hepatic vein (arrow). Both vena contracta width >7 mm and systolic flow reversal in hepatic veins (with patient in sinus rhythm) are specific for severe TR. Continuous-wave Doppler of tricuspid regurgitant jet (right) shows dense, early peaking jet, also consistent with severe tricuspid regurgitation.



Fig 6.23


3D echocardiography from atrial perspective reveals typically appearing rheumatic mitral valve with thickening of both leaflets. Tricuspid valve leaflets are also thickened, and valve appears bileaflet due to fusion of septal and posterior leaflets. In real time, there is incomplete coaptation of tricuspid leaflets.



Fig 6.24


At time of right atriotomy, there is severe thickening of tricuspid apparatus. Arrows indicate fused posterior and septal leaflets.



Fig 6.25


Postoperatively, tissue prostheses were placed in both tricuspid and mitral positions. In this four-chamber image, tissue valves are seen in systole (left panel) and diastole (right panel).




Comments


Most patients with rheumatic mitral stenosis have significant tricuspid regurgitation. The cause of tricuspid regurgitation may be rheumatic involvement of the tricuspid valve leaflets and chords but often the tricuspid leaflets are unaffected by rheumatic disease. Functional tricuspid regurgitation is present in about 80% of patients with rheumatic mitral stenosis and about 40% of those with severe rheumatic mitral regurgitation.


In these patients, chronic pulmonary hypertension secondary to mitral stenosis results in right ventricular and tricuspid annular dilation. With severe annular dilation, the normal tricuspid leaflets cannot completely close in systole, leading to tricuspid regurgitation. It is postulated that the additional right ventricular volume overload from tricuspid regurgitation leads to further right ventricular enlargement and progressive tricuspid regurgitation. In addition, there may be subtle rheumatic involvement of the tricuspid leaflets that may be better evaluated by 3D echocardiography.


Suggested reading




  • 1.

    Bruce CJ, Connolly HM: Right-sided valve disease in adults. In Otto CM, editor: The practice of clinical echocardiography, ed 5, Philadelphia, 2016, Elsevier.





Rheumatic heart disease


CASE 6-2


Rheumatic mixed tricuspid disease associated with mitral stenosis


This 36-year-old woman had long history of valvular heart disease secondary to rheumatic fever. She had suffered a stroke 15 years before admission, thought to be embolic in nature, and was started on warfarin. She now presented with increasing fatigue and shortness of breath, and clinical evidence of congestive heart failure.



Fig 6.10


Chest radiography revealed global cardiomegaly and central pulmonary congestion.



Fig 6.11


In TEE four-chamber plane at 0-degree rotation, zoom image of tricuspid valve in systole reveals significant leaflet thickening. Color Doppler flow imaging demonstrates moderate tricuspid regurgitation with vena contracta width of 4 mm. There is coexistent mitral stenosis, with spontaneous contrast visible in enlarged left atrium.



Fig 6.12


In same image plane as Fig 6.11 , diastolic image shows doming of tricuspid leaflets, consistent with rheumatic disease, with narrow antegrade flow stream suggesting tricuspid stenosis.


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Dec 30, 2019 | Posted by in CARDIOLOGY | Comments Off on Right-sided valve disease

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