Tricuspid and Pulmonary Valves

Solomon Aronson¹

Rebecca A. Schroeder²

Jonathan B. Mark²

Katherine A. Grichnik²

¹OUTLINE AUTHOR

²ORIGINAL CHAPTER AUTHORS

▪ KEY POINTS

Clinically significant tricuspid regurgitation (TR) is most commonly secondary to left-sided pathology or pulmonary hypertension.
The best views in which to evaluate the tricuspid valve (TV) are the midesophageal four-chamber view, the right ventricular (RV) inflow-outflow view, the midesophageal modified bicaval view, and the transgastric RV inflow view.
Most useful views for evaluation of the pulmonary valve (PV) are the midesophageal RV inflow-outflow view, the transgastric RV inflow view, and the upper esophageal aortic short-axis view.
Differentiation of physiologic from pathologic TR involves examination of hepatic venous flow patterns, peak TR jet velocity, relative RV and right atrial (RA) size, and pattern on color flow Doppler analysis.
The TV apparatus is distinguished by its poorly defined annulus, its large anterior and small septal and posterior leaflets, and its corresponding large anterior, small septal, and posterior papillary muscles.
The PV apparatus differs from the aortic valve (AV) structure by its ill-defined annulus and slightly smaller size.
Estimations of PA systolic pressure are best made from the midesophageal modified bicaval view. By this approach, the direction of TR flow is best aligned with the direction of the ultrasound beam.
In the Ross procedure, the PV is transplanted to the AV position and replaced with a homograft.
The ascending main pulmonary artery can be well visualized in multiple views, allowing anatomic assessment of this structure. The right main pulmonary artery can also be visualized and assessed for pathology, as well as positioning of a pulmonary artery catheter.

I. TRICUSPID VALVE (FIG. 12-1; VIDEOS 12-1 AND 12-2)

The TV consists of anterior, posterior, and septal leaflets, with the largest being the septal leaflet (Fig. 12-2).
The normal TV area, 7 to 9 cm², is larger than any other valve.
In the presence of normal leaflets, TR is termed functional and most likely due to RV dilation and/or dysfunction.
TR primarily due to leaflet abnormalities is rare and includes carcinoid syndrome, rheumatic mheart disease, and endocarditis.
The normal tricuspid annular diameter is larger and more apical than the mitral annulus.
The TV has three papillary muscles the anterior, posterior, and septal, with the anterior being the largest arising from the moderator band.

II. TRANSESOPHAGEAL ECHOCARDIOGRAPHIC EXAMINATION OF THE TRICUSPID VALVE

A. Anatomy and Image orientation

The TV lies in the far field relative to the esophagus, making imaging difficult.
In the midesophageal four-chamber view (image) typically the anterior (but could be posterior) and septal leaflets are seen (Video 12-1).
In the midesophageal RV inflow-outflow view (image), the posterior and anterior leaflets are seen on the left and right of the image screen, respectively (Video 12-3).
In the transgastric RV inflow view (Video 12-4) the posterior leaflet is in the near field and the anterior leaflet is in the far field.