Tricuspid Valvular Disease

Babar Fiza

Natalie Ferrero

Amit Prabhakar

Craig S. Jabaley

1. Which of the following best describes the three leaflets of the tricuspid valve?

A. Coronary, noncoronary, right coronary

B. Anterior, lateral, posterior

C. Anterior, posterior, septal

D. Anterior, noncoronary, septal

View Answer

1. Correct Answer: C. Anterior, posterior, septal

Rationale: The tricuspid valve consists of three leaflets: anterior, posterior, and septal. The anterior leaflet is the largest leaflet, the posterior leaflet is the smallest, and the septal leaflet is the most medially located and the most immobile.

Selected Reference

1. Huttin O, Voilliot D, Mandry D, Venner C, Juillière Y, Selton-Suty C. All you need to know about the tricuspid valve: tricuspid valve imaging and tricuspid regurgitation analysis. Arc Cardiovasc Dis. 2016;109:67-80.

2. On an apical four-chamber view of a normal heart, which of the following anatomic features best distinguishes the tricuspid valve from the mitral valve?

A. The tricuspid and mitral valves cannot be distinguished on an apical four-chamber view.

B. The insertion of the mitral valve is located closer to the cardiac apex compared to the tricuspid valve.

C. The septal leaflet insertion of the tricuspid valve is located closer to the base compared to the anterior mitral valve.

D. The septal leaflet insertion of the tricuspid valve is located closer to the cardiac apex compared to the septal leaflet insertion of the mitral valve.

View Answer

2. Correct Answer: D. The septal leaflet insertion of the tricuspid valve is located closer to the cardiac apex compared to the septal leaflet insertion of the mitral valve.

Rationale: The septal leaflet of the tricuspid valve is characteristically inserted more apically than the septal insertion of the anterior mitral valve leaflet. This allows for the differentiation of the tricuspid valve from the mitral valve on an apical four-chamber view during two-dimensional TTE.

Selected Reference

1. Shah PM, Raney AA. Tricuspid valve disease. Curr Probl Cardiol. 2008;33(2):47-84.

3. Which of the following echocardiographic features is most associated with moderate tricuspid regurgitation (TR)?

A. Vena contracta (VC) width >0.7 cm

B. Dilated right ventricle

C. Systolic blunting of the hepatic vein flow

D. Large central jet >50% of right atrium (RA)

View Answer

3. Correct Answer: C. Systolic blunting of the hepatic vein flow

Rationale/Critique: Systolic blunting of the hepatic vein is seen in moderate TR.

The following criteria are recommended by the American Society of Echocardiography for grading severe TR:

Dilated annulus with no valve coaptation or flail leaflet
Large TR central jet >50% of RA
Vena contracta (VC) width >0.7 cm
Proximal isovelocity surface area (PISA) radius >0.9 cm
Systolic reversal of hepatic vein flow
Dilated right ventricle with preserved function

Selected Reference

1. Zoghbi WA, Adams D, Bonow RO, et al. Recommendations for noninvasive evaluation of native valvular regurgitation. J Am Soc Echocardiogr. 2017;30:303-371.

4. A 66-year-old woman with a history of rheumatic heart disease presents to the preoperative clinic prior to inguinal hernia repair. Her most recent echocardiographic examination is notable for dilated inferior vena cava (IVC), enlarged RA, and pressure half-time (PHT) of 220 m/s across the tricuspid valve on Doppler interrogation. Based on this information, what is the calculated tricuspid valve area (TVA)?

A. 0.86 cm²

B. 1 cm²

C. 1.15 cm²

D. 1.5 cm²

View Answer

4. Correct Answer: A. 0.86 cm²

Rationale: In patients with tricuspid valve stenosis, TVA can be calculated by the PHT method. The TVA is derived using an empirical formula: TVA = 190/PHT. In Question 26.4,

TVA = 190/220 = 0.86 cm²
PHT is the time required for the pressure gradient across an obstruction to decrease to half of its maximal value.

Thus, the worse the obstruction (e.g., smaller transvalvular orifice), the more time required for the maximal gradient value to decrease. PHT is obtained by tracing the deceleration slope of the E-wave on the Doppler spectral display of the transvalvular flow.

Selected Reference

1. Baumgartner H, Hung J, Bermejo J, et al. Echocardiographic assessment of valve stenosis: EAE/ASE recommendations for clinical practice. J Am Soc Echocardiogr. 2009;22:1-23.

5. A 76-year-old man presents to the preoperative area prior to scheduled cystoscopy. His most recent echocardiographic examination is notable for an enlarged RA, dilated IVC, mean pressure gradient of 6 mm Hg across the tricuspid valve, and PHT of 200 m/s. His vital signs are notable for a heart rate of 80 bpm and blood pressure of 130/80 mm Hg. These findings best describe which of the following?

A. Nonhemodynamically significant tricuspid stenosis

B. Hemodynamically significant tricuspid stenosis

C. Mild physiologic tricuspid stenosis

D. Normal tricuspid function

View Answer

5. Correct Answer: B. Hemodynamically significant tricuspid stenosis

Rationale: Echocardiographic findings that indicate hemodynamically significant tricuspid stenosis include:

Mean pressure gradient ≥5 mm Hg
Inflow time-velocity integral >60 cm
PHT ≥190 ms
Valve area by continuity equation ≤1 cm²
Additional supportive findings include enlarged RA and dilated IVC
Mild TR in the setting of structurally normal tricuspid valve is seen in healthy subjects.

Selected Reference

1. Baumgartner H, Hung J, Bermejo J, et al. Echocardiographic assessment of valve stenosis: EAE/ASE recommendations for clinical practice. J Am Soc Echocardiogr. 2009;22:1-23.

6. The arrow points to which of the following tricuspid valve leaflets in Figure 26.1?

Figure 26.1

A. Anterior

B. Septal

C. Posterior

D. Either septal or posterior

View Answer

6. Correct Answer: B. Septal

Rationale: Due to the complex anatomy of the tricuspid valve and its retrosternal location, all three leaflets of the valve cannot be visualized simultaneously on 2D TTE. In 2D TTE, the tricuspid valve leaflets can be visualized from the parasternal long (RV inflow), parasternal short at the aortic valve level, apical four-chamber, and the subcostal views. On apical four-chamber view, the anterior and septal leaflets are visible, with the septal leaflet adjacent to the interventricular septum and the anterior leaflet adjacent to the RV free wall (Figure 26.7).

Figure 26.7

In contrast to the apical four-chamber view, on parasternal RV inflow and the parasternal short-axis views, visualized tricuspid valve leaflets can vary depending on the imaging plane of the acquired view. On parasternal long-axis RV inflow view, the displayed leaflets include the anterior leaflet and either the septal or the posterior leaflet. On parasternal short axis (PSSX), the displayed leaflets include the posterior leaflet and either the septal or the anterior leaflet.

Selected Reference

7. A 46-year-old man with a history of intravenous drug use presents to the intensive care unit (ICU) with respiratory failure and circulatory shock. A right internal jugular central venous line is placed, and an echocardiogram is performed by the intensive care team. A parasternal long-axis right ventricular (RV) inflow view of the heart is shown in

Video 26.1 and a Doppler velocity of TR jet in Figure 26.2. Vital signs are as noted in Table 26.1.

Table 26.1 Vital Signs

Blood pressure 96/40

Heart rate 94

Central venous pressure 10 mm Hg

Temperature 38.7 °C

Figure 26.2

Based on the hemodynamic data and echocardiographic evaluation, what is the estimated RV systolic pressure (RVSP) in this patient?

A. 41 mm Hg

B. 76 mm Hg

C. 56 mm Hg

D. 96 mm Hg

View Answer

7. Correct Answer: A. 41 mm Hg

Rationale: The RVSP is estimated by measuring the TR V_max using continuous-wave spectral Doppler. In the absence of RV outflow tract (RVOT) obstruction or pulmonic stenosis, RVSP is equal to the PASP. From the tricuspid regurgitant jet velocity, RVSP is estimated using the modified Bernoulli equation. RVSP = 4 (V_max m/s)² + RA pressure. Central venous pressure is often used as a surrogate of the right atrial pressure (RAP).

In this patient, the RVSP = 4 (2.80)² + 10 = 41.36 mm Hg. Note that for the RVSP calculation, the TR V_max is defined in m/s.

Selected Reference

1. Rudski LG, Lai WW, Afilalo J, et al. Guidelines for the echocardiographic assessment of the right heart in adults: a report from the American Society of Echocardiography. J Am Soc Echocardiogr. 2010;23(7):685-713.

8. A 60-year-old woman with septic shock due to bacterial pneumonia presents to the ICU. Patient is hypotensive and hypoxemic on arrival to the ICU. A transthoracic echocardiographic (TTE) examination is performed by the intensive care team. Based on the echocardiographic images (