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The tricuspid valve in the spotlight

Non-Invasive Imaging

The seminar on “Tricuspid valve in the spotlight” addressed four different topics.
The first talk by Ivan Stankovic of Belgrade addressed the pitfalls of 2D echo in the assessment of the tricuspid valve. The unfavourable position together with a complex anatomy are the main factors responsible for the difficulties of 2D imaging. In addition, it is important to highlight the fact that we are dealing with a complex structure that includes not only the leaflets but also the annulus, with a 3D geometry, chordae and the relation with the right ventricle. It was demonstrated through different examples how to avoid some potential pitfalls, for example by using different views, in particular the subcostal view.
The advantages of using 3D echo were then explained and an example of a pseudo-functional tricuspid regurgitation was shown. This was a case that on a 2D image appeared to be due to annular dilatation, but in fact was a prolapsed tricuspid valve, which was clearly demonstrated by 3D echo.
The second talk by Denisa Muraru from Pisa was on “Tricuspid regurgitation: what 3D echo can add”. It was shown that effective valve function depends on the structural integrity and functional coordination of all the components of the tricuspid valve complex.
The presenter showed several examples of how 3D echo can provide images comparable to anatomic specimens, therefore reproducing the 3D nature of the structures and improving visualization. Examples of iatrogenic tricuspid regurgitation (TR) in heart transplantation following biopsy, endocarditis, catheter-induced TR, and vegetations, amongst others, were shown. The relevance of 3D echo in improving our understanding of pathophysiology was also underlined, with a demonstration of the fact that in functional TR, the annulus becomes larger, rounder and flatter with the worsening of TR.
The speaker also showed the highly dynamic shape of the normal annulus, which is largest in late diastole and smallest at the onset of systole. It was shown how 3D echo can help to understand the mechanism of functional TR, for instance by visualization of the papillary muscles or demonstration of tricuspid tenting. In this case, the quantification of tricuspid valve tenting volume can help to optimize annuloplasty techniques. Finally it was shown how 3D echo can quantify TR through the vena contracta area or by obtaining 3D PISA.
The third presentation by Covadonga Fernandez-Gofin Loban from Madrid was on “Non-echo approaches to the Tricuspid Valve”. He showed the potential advantages and some limitations of using cardiac CT and cardiac MR in the assessment of the valve anatomy, function and impact on the right ventricle. The possibility of quantification of tricuspid regurgitation was also illustrated. Many examples were shown to demonstrate the potential uses.
The fourth and final talk by Jae-Kwan Song of Seoul addressed post-operative assessment and predictors of recurrence. Four main areas were addressed: the various causes of TR, the difficult hemodynamic assessment, the vague prognostic indicators in functional TR and the selection of the type of surgical intervention. The geometric changes in the annulus after valve repair were shown as one of the mechanisms of residual TR, which 3D echo can help to define. The poor surgical outcome and the development of late significant TR remain challenging issues, and the introduction of new imaging modalities may help to better select both patients and type of intervention.




The tricuspid valve in the spotlight

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.