013 // Tricuspid Valve Disease

Basics

Morphology

3 leaflets NOTE:
The posterior
Larger than MV (3.2-6.4 cm2) leaflet is usually
very small!
More apical and thinner leaflets
than MV

How to Image the Tricuspid Valve

RV PLAX ant. + post. leaflet

ant./sept. +post
RV inflow-outflow view
leaflet

RV optimized 4 ch view sept. + ant. leaflet

RV inflow: E/A wave lower than MV inflow, velocity varies with respiration

Causes of Tricuspid Regurgitation

Prognosis of TR

Survival poor if TR severe NOTE: Trivial

(physiologic) TR
+ PHT
is common!
+ reduced LVF (70% of adults)

+ reduced RVF

Causes of Functional Tricuspid Regurgitation

Left heart disease Mitral valve disease

Pulmonary hypertension RV dilation (ASD/left right shunt)

NOTE: Functional (secondary) TR is much more common than structural

(primary) TR!

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013 // Tricuspid Valve Disease

Causes of Primary TR
NOTE:
Rheumatic (TR comb. with TS) If the plane of the
tricuspid valve is
Trauma (blunt trauma, flail/
displaced towards
rupture)
the apex consider
Pacemaker lead associated rudimentary form
of M. Ebstein or
Endocarditis Tricuspid valve
dysplasia!
Congenital (i.e. M. Ebstein)

Carcinoid Tricuspid Regurgitation

Release of vasoactive substances (i.e. serotonin) leads to:

Endocardial fibrosis (TV, PV,

TV leaflet restriction
RV endocardium, LV (PFO)

can be associated with

Wide coaptation defect
pulmonic stenosis

NOTE: Left valve involvement can be found in the presence of ASD or PFO!

Morbus Ebstein

Variable morphology Large anterior leaflet

Apical displacement (atrialized

Leaflet tethering
RV)

Associated with: ASD, VSD, PDA, CoA, RVOT obstruction

NOTE: The origin of the TR jet is far in the right ventricle caused by apical
displacement of the tricuspid valve!

Quantification of Tricuspid Regurgitation

Quantification

Flow convergence Vena contracta

Jet area Jet length

Eye-balling

NOTE: The degree of tricuspid regurgitation can vary to some extent with
respiration! Observe several beats with Echo!!

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013 // Tricuspid Valve Disease

Tricuspid Regurgitation — Reference Values

Mild Moderate Severe

PISA < 0.5 cm 0.6 - 0.9 cm > 0.9 cm

Nyquist limit 28 cm/s

Vena contracta >0.7 cm

Nyquist limit 50-60 cm/s

Signs of Severe TR

Dilated RV Dilated RA

Systolic flow reversal

Dilated VCI
(hepatic veins)

Flattened IVS (diastole) Visible coaptation defect

TV Surgery — Rules

Surgery before RV failure

Surgery if TR ≥ moderate in heart surgery

No surgery if RVF is severely reduced

Repair is better than replacement

Tricuspid Stenosis

Overview
NOTE:
In 9 % of rheumatic heart disease Look for
doming of
Congenital TS (very rare) TV in 2D
and
Functional TS due to masses (very rare) turbulent
flow in the
Endocarditis ( very rare) color
doppler!
Following repair/replacement!

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013 // Tricuspid Valve Disease

Hemodynamics

RA-RV gradient (increase

Elevated pressure in RA
with inspiration)

Dilated RA Dilated VCI

Quantification of Tricuspid Stenosis

PHT: TVA = 190/PHT (is not validated)

Mean gradient: Significant TS if > 5mmHg

Severe TS: TVA < 1.0 cm2

NOTE: Look for turbulent flow in the color doppler across the TV in all
patients with mitral stenosis!! Doming of the tricuspid valve is often difficult
to visualize! Thereby you won‘t miss associated TS!