Tricuspid Valve Anatomy Research Articles

Predictors of residual tricuspid regurgitation after interventional therapy: an automated deep-learning CT analysis

Computed tomography (CT) is used as a valuable tool for device selection for interventional therapy in tricuspid regurgitation (TR). We aimed to evaluate predictors of TR reduction using CT and automated deep learning algorithms. Patients with severe to torrential TR and CTs prior to either percutaneous annuloplasty (PA) or tricuspid transcatheter edge-to-edge repair (T-TEER) were enrolled. CTs were analyzed using automated deep learning algorithms to assess tricuspid valve anatomy, right heart morphology, and function. Outcome parameters comprised post-interventional TR ≤ 1 and all-cause mortality. 84 patients with T-TEER (n = 32) or PA treatment (n = 52) were enrolled. Patients with a post-interventional TR ≤ 1 presented lower tenting heights and smaller tenting angles compared to patients with a TR > 1. Tenting height showed the best accuracy for post-interventional TR > 1 with an AUC of 0.756 (95% CI 0.560–0.951) in the T-TEER and 0.658 (95% CI 0.501–0.815) in the PA group, consistent with a suggested threshold of 6.8 mm and 9.2 mm, respectively. Patients with a post-interventional TR ≤ 1 exhibited a mortality of 4% and those with a TR > 1 of 12% during a follow-up of 331 ± 300 and 370 ± 265 days, respectively (p = 0.124). To conclude, tenting is associated with procedural outcomes and should be considered during screening for interventional TR therapy.

A Novel Swine Model for Inducing Functional Tricuspid Valve Regurgitation

Functional tricuspid regurgitation (FTR) is the most common TR, although experimental models to effectively study it are scarce; therefore, this study aimed to establish a robust experimental swine model. A swine FTR model was developed using radiofrequency ablation, atrial septostomy, and right atrial volume overload. The baseline and follow-up echocardiography was performed to evaluate the progression FTR and changes in the heart. Autopsy was employed to verify the anatomy of tricuspid valve. One-month post intervention, among the subjects, one (8.3%) exhibited severe FTR, eight (66.7%) exhibited moderate TR, and three (25%) exhibited mild FTR. Each pig developed an atrial septal defect (diameter, 1.5 ± 0.5 cm). The tricuspid annular diameter significantly increased with enlargement of right heart (P < 0.05). No significant difference was found on left heart size and mitral regurgitation. We successfully developed a novel swine FTR model, providing a reliable and effective platform for further research on FTR.Graphical The procedure to induce the FTR model on swines

Contemporary evaluation and treatment of tricuspid regurgitation.

Valvular heart disease is a global health burden with substantial mortality. The left-sided valvular diseases have been extensively described using the robust treatment strategies available. By contrast, the right-sided diseases, particularly the tricuspid valve (TV) and associated regurgitation, still have much to be delineated. Worsening tricuspid regurgitation (TR) is associated with increased mortality; the non-invasive management is suboptimal; and surgical approaches carry significant risk. With advances in multimodality imaging, 3D echocardiography, improved understanding of TV anatomy, and pathophysiological mechanisms of primary and secondary regurgitation, as well as favorable data with transcatheter therapies, the field of TV management is rapidly evolving. This review aims to highlight pathophysiological mechanisms of TR, describe echocardiographic approaches to diagnosis and TV interrogation, and outline the latest transcatheter developments.

Characterization of Tricuspid Valve Anatomy and Coaptation Gap in Subjects Receiving Tricuspid Transcatheter Edge-To-Edge Repair: Observations From the bRIGHT TriClip Study

Transcatheter edge-to-edge repair (TEER) for the treatment of tricuspid regurgitation (TR) has experienced fast adoption following commercial approval. Defining the appropriate target population for TEER therapy is important to guide patient selection. The aim of this study was to characterize tricuspid valve anatomy and coaptation gap in subjects receiving TEER for the treatment of TR in a contemporary postmarket setting. The bRIGHT study is a prospective, multicenter, single-arm, postmarket study evaluating the safety and effectiveness of the TriClip device. Procedural outcomes included implant success, acute procedural success, TR severity, major adverse events, single-leaflet device attachment, and embolization through 30 postprocedure days. Tricuspid valve characteristics, including morphology, annulus size, and leaflet mobility, were assessed via two-dimensional transesophageal echocardiography from the screening visit by an independent echo core lab to characterize subject variability. Coaptation gap measurements were taken in both the transgastric short-axis (TG SAX) and RV inflow/outflow views. The independent echo core lab performed a detailed assessment of the tricuspid valve on 135 consecutive subjects with available TG SAX views from 24 sites. Tricuspid valve morphologies included 2 to 5 leaflets, with a non-trileaflet valve in 28% of subjects and ≥4 leaflets in 21% of subjects. The etiology of TR was functional in 91% (96/105), mixed in 7% (7/105), and lead induced in 2% (2/105) of subjects. Leaflet mobility was mildly restricted in 69% (78/113) and moderately restricted in 7% (8/113) of subjects. Annulus diameter averaged 4.7±0.7cm with a range of 2.5 to 6.2cm. From the TG SAX view, the coaptation gap measured 8.1±3.1 and 5.2±2.3mm in the central and mid regions of the anterior-septal coaptation line and 6.6±3.2 and 3.8±2.1mm in the central and mid regions of the septal-posterior coaptation line, respectively. From the right ventricular inflow/outflow view, the coaptation gap measured 4.7±2.4, 5.2±2.4, and 4.6±3.0mm in the anterior, mid, and posterior regions of the tricuspid valve, respectively. Thirty-day TR reduction (by number of grades) was similar among subjects with coaptation gaps of <7mm, 7 to 10mm, and >10mm. A broad range of anatomies was observed in this postmarket population. Characterization of the tricuspid valve and coaptation gap will help to better understand and better define the target patient population for tricuspid TEER therapy.

Tricuspid Transcatheter Edge-to-edge Repair

Tricuspid regurgitation (TR) is a common disease associated with significant morbidities and mortality. In this review, the new grading scheme of TR, the tricuspid valve anatomy and also the different TR mechanisms are summarised. Recently, there have been many evolving technologies to treat TR, and transcatheter edge-to-edge repair is one of the most well-established techniques. Transcatheter edge-to-edge repair is shown to be effective in TR reduction. With increasing clinical experience, a number of echocardiographic predictors of optimal TR reduction have been identified, and a standardised transoesophageal echocardiogram protocol and also different techniques to improve the procedural success are presented. Finally, the uncertainties on the optimal timing of TR intervention and on the clinical benefit of transcatheter edge-to-edge repair are also addressed.

Transcatheter Tricuspid Valve Replacement: Case Selection, Technical Considerations, and Procedural Planning

Tricuspid regurgitation (TR) is a highly prevalent valve disorder in the US, with prevalence increasing with age. Without treatment, severe TR carries a poor prognosis. Tricuspid valve (TV) surgery is recommended for patients with severe TR undergoing left-sided valve surgery. Transcatheter TV repair or transcatheter TV replacement are potential options for patients who are not surgical candidates. A few small studies have demonstrated the feasibility and efficacy of transcatheter TV repair in patients with severe symptomatic TR. Careful patient selection by assessing tricuspid valve anatomy, right ventricular and pulmonary hemodynamics, candidacy for anticoagulation, comorbid conditions, and frailty is key to procedural success. Transcatheter TV repair can be performed via the transjugular or transfemoral access, and requires a large-caliber sheath (up to 45 Fr) and delivery system, particularly with dilated tricuspid annulus due to right ventricular enlargement. Multimodality imaging is essential for diagnosing TR severity, defining valve anatomy, and comprehensive functional assessment of the tricuspid valve, right atrium, and right ventricle. Several prosthetic valves, including the EVOQUE system, NaviGate system, Intrepid valve, and Cardiovalve, are currently being investigated in clinical trials.

Accuracy of the simple 3D transthoracic echocardiography in the definition of tricuspid valve and right ventricle anatomy

Abstract Funding Acknowledgements Type of funding sources: None. Introduction The interest in the "forgotten" valve has re-emerged in recent years in consideration of the high mortality rate related to the highest degrees of TR and the recognition of a large amount of patients who remains under treated. Transcatheter tricuspid valve interventions (TTVI) represent a valuable option in high risk surgical candidates when specific anatomic criteria are met. Tailoring the most suitable therapeutic percutaneous strategy for each patient is crucial: an accurate screening aims to quantify regurgitation grade and fully understand the underlying mechanism. Transthoracic and transesophageal is used to assess jet location, leaflets anatomy and motion. ECG-gated Cardiac TC is necessary for the selection of annuloplasty or replacement techniques. Purpose Aim of the study is to compare three different imaging modalities as 3D transthoracic echocardiography (TTE), transesophageal one (TOE) and ECG-gated Cardiac CT for the definition of tricuspid valve anatomy, annular dimensions and right ventricle geometry in patients screened for TTVI. Methods Twenty-one (Age 79 ± 7 years, Female 72%) patients, referred with a diagnosis of at least severe TR in evaluation for percutaneous treatment, were prospectively enrolled in the study and underwent TTE, TOE and Cardiac CT. All measurements were performed in double blind by three different operators and compared. Results In the comparison between 2D/3D TTE and 2D/3D TOE no statistically significant differences were found regarding the evaluation of the valve anatomy, the site of regurgitation and the underlying mechanism (TTE vs TOE: 3D septo-lateral diam 45,8± 4,92 vs 45,87 ± 4,98 mm, p = 0.87; 3D antero-posterior diam 43,5 ± 4,58 vs 43,5 ± 4,53 mm, p = 0.59; Circularity index 0,75± 0,08 vs 0,76± 0,08, p = 0.98; 3D Annular area 16,48±3.9 vs 15,97±3,75 cm2, p = 0.77; Annular perimeter 14,82±1,62 vs 14,93±1,9 cm, p = 0.54). From the double-blind comparison between 3D TTE and Cardio CT, no differences emerged regarding anatomic annulus parameters (area 17,58± 3 vs 17.71±4,3 cm2, p = 0.1; perimeter 14,89±1,6 vs 14,29±1 cm, p = 0.5; maximum diameter 50,5 ± 5 vs 50,6 ± 5.1mm, p = 0.19; minimum diameter 40,25±3.8 vs 41.16± 4,9mm, p = 0.28). Similarly, in the study of right ventricular dimensions, obtained through 3D volumetric reconstruction, TTE was not statistically different to Cardiac CT (3DTTE vs CT: RVD1 51,14 ±2,54 vs 49,42 ± 5 mm, p = 0.5; RVD2 40,62±7,9 vs 40±11 mm,p = 0.7; RVL 72, 12±7 vs 72,12±11 mm, p = 0.8). Conclusions Three-dimensional trans-thoracic echocardiography showed an optimal performance to define tricuspid valve anatomy and right ventricle dimensions when compared with other imaging methods. 3D TT can be safely used for an overall first line in periprocedural evaluation of patients candidates for TTVI, allowing for elaborated study of the characteristics of TR through MPR reconstructions, annular and valvular anatomy, right chambers size and function.

Transcatheter tricuspid valve repair: results according to TV morphology

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Tricuspid regurgitation is a prevalent and undertreated condition. Transcatheter edge-to-edge tricuspid valve repair (TTVR E2E) is an emergent option with promising procedural results in clinical trial and selected high-experienced centres. Tricuspid valve (TV) anatomy is highly variable. Whether different morphologies have a clinical or procedural impact over TTVR results are unclear. Purpose Our aim is to define the procedural, clinical and echocardiographic results of TTVR E2E technique in a "real-world" population according to TV anatomy. Methods We collected all TTVR E2E cases from 8 University Hospitals with large experience in SHDI from 2017 to 2022. It was a prospective inclusion, not randomized (real-world clinical practice). The TV morphology according to Hahn R. et al classification. Different devices (Mitraclip, Triclip &amp; PASCAL) were employed. Clinical and echocardiographic follow-up were collected at 3 &amp; 12 months after index procedure. We defined a combined clinical endpoint of all-cause death, HF admission and TV reintervention Results 147 consecutive patients were recruited (74 years old, 74% female). The baseline profile was HTN 68%, DM-2 21%, DLP 44%, atrial fibrillation 91%, previous CAD 19% and previous cardiac surgery 42%, COPD 19% and CKD 42%, STS mean 5,8 pts. The TR was ≥severe in all patients (vena contracta mean 12mm, gap size 7mm). According to the procedure, the most employed device was Triclip XT (70%, 1,7 devices/patient, 89% in anteroseptal commissure), with a procedural success of 99% and 93% without clinical complications. In our cohort, TV anatomy was conformed by 3 leaflets in 56% and 4 leaflets in 37% of cases. The morphology distribution was type I (50%), IIIB (31%), and a much lower frequent distribution of the other types (Figure 1). A significant TR reduction was accomplished in all TV morphologies without significant differences between them (Figure 2). The most frequent morphology (type I) versus the rest of morphologies, not revealed differences in terms of TR reduction or combined clinical endpoint. Restrictive septal leaflet presence (39%) is related with higher partial detachment prevalence (87 vs 17%, p 0,03). No other morphology parameters were related with procedural or clinical endpoint. Conclusions TV morphology was highly variable (50% of patients are non-Type I) being type I and IIIB the most prevalent. Posterior leaflet anatomy was the highest variable. Not differences were noted in TR reduction or clinical outcomes according to TV morphology. A restrictive septal leaflet were related with higher prevalence of partial detachment.

Echocardiographic classification of anatomical diversity of the tricuspid valve: insights from the bright trial

Abstract Funding Acknowledgements Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Trial funded by Abbott Background As the treatment of tricuspid regurgitation with tricuspid transcatheter edge-to-edge repair (TEER) becomes more widespread, a better understanding of tricuspid anatomy is increasingly important to properly select patients for this therapy. The diversity of tricuspid anatomies in the real-world population is not well known, and strategies for characterization of some anatomic features are not well defined. Purpose To propose a method to accurately and consistently characterize the tricuspid valve anatomy with transthoracic and transesophageal echo in patients receiving tricuspid TEER and investigate the diversity of tricuspid valve anatomies reflected in a real-world population. Methods The bRIGHT trial is a prospective, single-arm, multi-center registry initiated to evaluate the safety and effectiveness of the TriClip transcatheter edge-to-edge repair (TEER) System in patients with severe tricuspid regurgitation (TR) in a real-world post-market setting. Detailed echocardiographic analysis was performed on subjects from 25 sites with available baseline echo. Subjects were evaluated for three key anatomical factors that are anticipated to be critical in determining the feasibility of TEER: number of tricuspid valve leaflets, degree of leaflet restriction, and coaptation gap size. Herein, we present a proposed method for characterizing these factors through echo analysis. Results Between August 2020 and July 2022, 312 patients subjects (age, 78.4±7.6 years, 54% women) at 25 sites were enrolled into the bRIGHT trial and 283 subjects had available baseline echo. Coaptation gap size was measured at the largest clippable location (Figure 1) and was found to range from 2.3 mm to 20.8mm (avg. 8.6 ± 3.3 mm). According to the analysis method proposed by Hahn et. Al, the majority of subjects were found to have 3 leaflets (80%), however 4 and 5 leaflet anatomies were also present (20% and 1% respectively). Severity of leaflet restriction was categorized according to a 4-grade scale. In the subjects studied, restriction severity ranged from none to severe, with 21% of subjects having no restriction, 65% displaying mild restriction, 12% displaying moderate restriction, and 2% severe restriction. Conclusions In this analysis of 283 subjects treated as part of the bRIGHT trial, a proposed method to accurately and consistently characterize the tricuspid valve anatomy from baseline echo was developed. The method reaved the broad range of tricuspid valve anatomies realized in this real-world population. ___________________________________

Three-dimensional echocardiography of the tricuspid valve.

Due to the proportionally high mortality rates associated with isolated tricuspid valve surgery, the invasive treatment of such pathology, historically, has been left largely unaddressed. Recently, there has been an appreciation for the mortality and morbidity of tricuspid valve disease, giving rise to the movement towards identifying less invasive, transcatheter approaches for treatment. Due to the technical complexity of these procedures along with the uniqueness and variability of tricuspid valve anatomy, a better appreciation of the tricuspid valve anatomy and pathology is required for pre-procedural planning. While two-dimensional echocardiography serves as the initial non-invasive modality for tricuspid valve evaluation, three-dimensional echocardiography provides a complete en face view of the tricuspid valve and surrounding structures, as well contributes further information regarding disease etiology and severity. In this review, we discuss the utility of three-dimensional echocardiography as a supplement to two-dimensional imaging to better assess tricuspid valve disease and anatomy to aide in future innovative therapies.

Evaluation of systemic impact of tricuspid regurgitation: an appleal for the notion of tricuspid regurgitation.

Evaluation of systemic impact of tricuspid regurgitation: an appleal for the notion of tricuspid regurgitation.

Tricuspid valve anatomy of massive to torrential tricuspid regurgitation: Computed tomography analysis

BackgroundWe aimed to comprehensively assess tricuspid valve anatomy and to determine factors associated with the more advanced stages beyond severe TR (i.e., massive to torrential). MethodsWe retrospectively analyzed the pre-procedural cardiac CT images in patients with ≥severe TR using 3mensio software. The tricuspid valve annulus size, right-atrial and right-ventricular dimensions, tenting height, and leaflet angles were measured. ResultsA total of 103 patients were analyzed. The mean effective regurgitant orifice area was 61.7 ​± ​31.5 ​mm2, vena contracta was 13.1 ​± ​4.6 ​mm, and massive/torrential TR was observed in 62 patients. Compared to patients with severe TR, patients with massive/torrential TR had a larger tricuspid annulus area (18.6 ​± ​3.4 ​cm2 vs. 20.6 ​± ​5.3 ​cm2, p ​= ​0.037), right atrial short-axis diameter (66.1 ​± ​9.1 ​mm vs. 70.6 ​± ​9.9 ​mm, p ​= ​0.022), increased tenting height (8.8 ​± ​3.6 ​mm vs. 10.7 ​± ​3.7 ​mm, p ​= ​0.014), and greater leaflet angles (anterior leaflet: 22 ​± ​9° vs. 32 ​± ​13°, p ​< ​0.001; posterior leaflet: 22 ​± ​11° vs. 30 ​± ​11°, p ​= ​0.003). In the multivariable logistic regression model, the angle of anterior leaflet (OR 1.08, 95%CI 1.03–1.14, p ​= ​0.004) and posterior leaflet (OR 1.07, 95%CI 1.02–1.13, p ​= ​0.007) were associated with massive/torrential TR. Additionally, patients with massive/torrential TR more often had TR jets from non-central/non-anteroseptal commissure (34% vs. 76%, p ​< ​0.001). In the multivariable model, a greater angle of the leaflets and a more elliptical annulus were associated with non-central/non-anteroseptal TR jets. ConclusionsAnterior and posterior leaflet angles are significant factors associated with massive/torrential TR. Furthermore, leaflet angles and ellipticity of the tricuspid valve are associated with the location of TR jets.

Many hands make light work. Echocardiography and computed tomography results from the Tricuspid Regurgitation IMAging (TRIMA) study

Abstract Background Anatomic knowledge of the tricuspid valve (TV) is the first step in the diagnostic algorithm of patients with tricuspid regurgitation (TR), who are candidates for transcatheter tricuspid valve intervention (TTVI). Currently, echocardiography and computed tomography (CT) are available instruments to study the TV anatomy, guide the decision-making process and support the development of novel transcatheter therapies. Purpose The Tricuspid Regurgitation IMAging (TRIMA) study aimed to correlate CT parameters to commonly used echocardiographic variables. Methods This prospective, single-center study enrolled 22 consecutive patients with TR equal to or greater than severe (≥3+). All patients underwent transthoracic echocardiogram (TTE), transesophageal echocardiogram (TEE) and cardiac CT study, in order to obtain anatomical dimensions of the tricuspid annulus and quantification of right-chambers remodeling and function. Novel CT scan measurements were analyzed. Correlation between measurements on echocardiography and CT imaging was assessed. Results Severe TR (3+) was present in 27.4% patients, massive (4+) in 4.8% and torrential (5+) in 3.2%. The mean right ventricle (RV) length, RV mid diameter, and right atrium area were 60.81±9.11 mm, 41.27±7.67 mm and 31.72±9.66 cm2, respectively. Tricuspid annular plane excursion, fractional area change, longitudinal myocardial velocity (S') were 16.09±3.25 mm, 33.36±9.47% and 9.18±1.94 cm/sec, respectively. The annular dimensions obtained by CT scan were generally observed to reduce from diastole to systole, except for eccentricity, angles and distance between the postero-septal and antero-posterior commissure and distance between centroid and antero-posterior commissure. A Kruskal-Wallis test showed a stepwise increase in the tricuspid anatomical regurgitant orifice area (AROA) values by CT across the expanded TR grades by TEE, χ2(2)=6,466, p=0.039. Using the Pearson correlation coefficient, we found a relationship between the AROA and TR grade (r=0.593; p&amp;lt;0.004), as well as ARO-perimeter and TR grade (r=0.470; p&amp;lt;0.027). Additionally, a significant correlation was found between septal lateral annulus diameter obtained by TEE and CT (r=0.637; p=0.001). Anyway, no correlations were found between novel CT variables and TR grade or RV function assessed by echocardiogram, as well as between CT systo-diastolic annulus variability and RV function. Conclusions Standard echocardiographic study provide invaluable information about the anatomy and function of the right-chambers, as well as an accurate grade of TR. Conventional and novel variables derived by CT scan may step up the anatomical assessment of the complex morphology of the TV apparatus, thanks to the high spatial resolution of the technique. Therefore, an integrated multimodality assessment is the key point of the screening process of TR candidates for TTVI. Funding Acknowledgement Type of funding sources: None.

732 TEE role in patients selection for transcatheter edge to edge tricuspid repair

Abstract Aims The natural history of tricuspid valve (TV) regurgitation is characterized by dismal prognosis and high in-hospital mortality when treated with isolated TV surgery. Although the anatomy and the imaging of the TV are very challenging, the edge-to-edge repair with the TriClip (Abbott Vascular, Santa Clara, CA) showed promising results. We report preliminary results of our experience with the TriClip System in a cohort of ‘real life’ patients with functional tricuspid regurgitation (TR). Methods and results From January to September 2021, 30 consecutive patients with severe TR has been screened, 8 underwent transcatheter TriClip repair. The anatomical feasibility was established according to a complete transesophageal echocardiogram (TEE) and a dedicated CT scan for the right cardiac chambers. All the echocardiographic projections focused on right ventricle were used during the procedure, with the aim of optimizing the visualization of the catheters and device with respect to the anatomical structures of the tricuspid valve complex. The procedure was conducted under general anesthesia, guided by TEE and fluoroscopy. In-hospital and 30-day clinical and echocardiographic outcomes were recorded. The annulus septo-lateral diameter was enlarged in all cases, and functional TR was present in all patients. In two patients, the pacemaker lead interfered with leaflets coaptation. TR jet was predominantly central. The implant and procedural success were achieved in all cases, implanting one device in five patients and two in three patients. The final TR grade was 2+ in four patients and and 1+ in the others. All patients were extubated in the catheterization laboratory. There were no procedural or in-hospital adverse events. At 30-day follow-up, we observed significant improvement in clinical and echocardiographic outcomes. Conclusions In our experience, 26% of screened patients were selected for the procedure. Favourable anatomical findings for the TV edge-to-edge repair were the following: moderate leaflet tethering (coaptation depth &amp;lt;10 mm); large annulus but with small coaptation gap (&amp;lt;7 mm); antero-septal or postero-septal jet location; commissural jet; small right ventricular dimensions; pacemaker lead with no leaflet tethering. The best transcatheter approach consists of obliterating the antero-septal coaptation rim for a more favourable angle between the inferior vena cava and valvular plane. High-quality TEE imaging during the procedure is required for obtaining procedural success. Patient selection and tricuspid valve anatomy characterization with TEE and cardiac CT scan is critical for procedural success and clinical improvements.

Multimodality Imaging of the Anatomy of Tricuspid Valve.

Even though the tricuspid valve is no longer “forgotten”, it still remains poorly understood. In this review, we focus on some controversial and still unclear aspects of tricuspid anatomy as illustrated by noninvasive imaging techniques. In particular, we discuss the anatomical architecture of the so-called tricuspid annulus with its two components (i.e., the mural and the septal annulus), emphasizing the absence of any fibrous “ring” around the right atrioventricular junction. Then we discussed the extreme variability in number and size of leaflets (from two to six), highlighting the peculiarities of the septal leaflet as part of the septal atrioventricular junction (crux cordis). Finally, we describe the similarities and differences between the tricuspid and mitral valve, suggesting a novel terminology for tricuspid leaflets.

Multimodality cardiac imaging and new display options to broaden our understanding of the tricuspid valve.

The prognostic impact of tricuspid regurgitation (TR) and the subsequent development of percutaneous procedures targeting the tricuspid valve (TV), has brought to the forefront the role of imaging for the assessment of the forgotten valve. As illustrated in several studies and summarized in this review, currently a multimodality imaging approach is required to understand the pathophysiology of TR, due to the complex TV anatomy and the close relationship between the severity of TR and the extent of the remodeling of the right heart chambers. Recently, the advance in the tranhscatheter treatment of the TV has led to a growing interest in the development of dedicated software packages and new display modalities to increase our understanding of the TV. As a consequence, a transversal knowledge of the different imaging modalities is required for contemporary cardiac-imaging physicians. This review highlights the main features, and the pros and cons of echocardiography, cardiac computed tomography, cardiac magnetic resonance and emerging technologies, as 3D printing and virtual reality, in the assessment of patients with TR.

Optimal Echocardiographic Approach to the Evaluation of Tricuspid Regurgitation.

To summarize the most recent literature on the optimal echocardiographic approach to the evaluation of tricuspid regurgitation (TR). Severe TR is increasingly recognized as an independent adverse prognostic marker. TR severity grading has been mainly based on qualitative and semiquantitative parameters according to the 2017 ASE guidelines, but new data emerging from 3D echocardiography and MRI will likely provide insights into more quantitative measurements of TR severity. The tricuspid valve's anatomy and physiology is complex and unique. TR can be primary or secondary to tricuspid annular dilatation. Commonly used echocardiographic parameters to define severe TR are severe valve lesions, a large color flow jet area, a vena contracta width of ≥ 7cm, a PISA radius of ≥ 0.9cm, a dense and triangular continuous wave Doppler jet shape, and hepatic vein systolic flow reversal. Complementary imaging modalities such as 3D echocardiography and MRI should be utilized if the 2D echocardiographic evaluation is suboptimal.

Comparison of different imaging modalities for the quantification of tricuspid valve geometry and regurgitation: a retrospective, single-center study.

Background and AimsTricuspid regurgitation (TR) is a frequent valvular heart disease with relevant adverse impact on patients' prognosis. Adequate TR imaging and evaluation is challenging. In this study, we aimed to compare different imaging modalities (echocardiography and multi‐slice computed tomography) for the assessment of tricuspid valve (TV) function and geometry.MethodsWe retrospectively investigated patients that presented to University Hospital Bonn, Germany, between September 2018 and March 2019, who underwent comprehensive echocardiography and multi‐slice computed tomography (MSCT) to evaluate TR. MSCT was considered the reference approach for dimensional assessment of TV anatomy and echocardiography (transthoracic echocardiography + transesophageal echocardiography) for functional assessment of TV. We used Spearman's Rank order correlation, Bland‐Altman analysis, and intra‐class correlation to compare the different imaging modalities.ResultsForty patients (Mean Age ± SD: 77.5 ± 7.1 years; 35% female) with high grade TR (effective regurgitant orifice area, EROA: 0.49 ± 0.3 cm2, RegVol: 49.5 ± 13.4 mL) were included. There was a statistically significant but moderate correlation between 2D‐TEE and MSCT for anteroposterior (AP) (r = 0.68, 95% confidence interval [CI]: 0.44‐0.93, P = .05; intraclass correlation [ICC]: 0.77, P = .03) and septolateral (SL) diameters (r = 0.71, 95% CI: 0.33‐0.93, P = .03; ICC = 0.76, P = .05). MSCT and 3D‐TEE showed a strong correlation for determination of TV annulus area (r = 0.94, 95% CI: 0.57‐0.98, P = .002; ICC = 0.95, P = .4), perimeter (r = 0.9, 95% CI: 0.6‐0.98, P = .002; ICC = 0.97, P = .3) and diameters (AP‐Diameter: r = 0.73, 95% CI: 0.06‐0.94, P = .03; ICC = 0.83, P = .09; SL‐Diameter: r = 0.86, 95% CI: 0.47‐0.97, P = .02; ICC = 0.95, P = .1). Only 3D‐TEE allowed for direct measurement of planimetric EROA, which exhibited a significant difference from calculated EROA (0.49 ± 0.4 cm2, 0.67 ± 0.17 cm2, P = .05; r = 0.93, 95% CI: 0.5 to 0.99, P = .006). According to Bland‐Altman analysis, we found a relevant agreement between MSCT and 3D‐TEE only for TV area (bias: −1.95, 95% limits of agreement −3.6 to −0.1).ConclusionOnly 3D‐TEE allowed for sufficient simultaneous functional and dimensional assessment of TR in our cohort.

Three-dimensional echocardiography for the assessment of the tricuspid valve.

Tricuspid valve pathology is increasingly recognized as an important contributor to patient morbidity. Accordingly, interest in transcatheter interventions for tricuspid valve disease has continued to grow. Echocardiographic imaging of the tricuspid valve has therefore become an integral component of patient assessment and the essential imaging modality for interventional procedures. The need for improved tricuspid valve imaging has highlighted the variability in tricuspid valve anatomy and the difficulties of using two-dimensional (2D) echocardiography alone to determine the location and type of tricuspid valve disease. Here, three-dimensional (3D) imaging using tools such as biplane imaging, multiplanar reconstruction and live 3D acquisition allow a more accurate and efficient evaluation of the tricuspid valve. The 3D imaging of the tricuspid valve is often focused on transesophageal echocardiography, but the more anterior location of the tricuspid valve also lends itself to assessment with transthoracic echocardiography. In this review, we will examine how 3D imaging can complement and enhance the information obtained from 2D echocardiography, and present novel applications for the quantitation of valvular disease and its utility in intraprocedural imaging.

P879 3D transoesophageal echocardiography to asses a case of a non-ebstein tricuspid valve congenital regurgitation

Abstract Introduction Due to the complexity of congenital heart disease and limitations of transthorathic echocardiogram (TTE), especially in adult patients, it is not unusual to need other image techniques to assess cardiac anatomy and function. The most common primary anomaly of tricuspid valve (TV) is Ebstein anomaly, but there are other much rarer primary anomalies of this valve consisting in prolapse, cord retraction.... without downward displacement of the leaflet, generally causing tricuspid regurgitation (TR) that can be severe and sometimes intervention is needed, preferably reparation. Due to anatomical issues, it is difficult to assess anatomy of TV in TTE, so sometimes 3D-TTE must be performed to clarify the mechanism and to measure orifice, but when transthoracic view is not enough, 3D transoesophageal echocardiogram (TOE) can be useful for this purpose. Case We report the case of a 15-year-old boy that was referred to our clinic because of shortness of breath and a systolic tricuspid murmur. TTE was performed and an image compatible with tricuspid valve prolapse with no apical displacement of any leaflets (Figure, A) causing severe TR (Figure, B) was noticed, as well as severely dilated right chambers, with good ejection fraction of both ventricles. It was not clear the mechanism so 2D TOE was done, showing a prolapse of a leaflet (Figure, C) causing severe TR (Figure, D). The mechanism was finally clarified by 3D TOE (figure E). This was a prolapse of lateral portion of posterior leaflet (asterisk) with restrictive movement of anterior (triangle) and septal (arrow) ones, causing a huge coaptation defect in systole leading to a very severe tricuspid insufficiency with signs of volume overload of right ventricle. There was no atrial septal defect and pulmonary drainage anomalies were ruled out by cardiac magnetic resonance. Patient was referred to surgery due to symptoms and great dilatation of right chambers. Conclusión: Due to anatomical complexity and limitations of echography, cross and multimodality cardiac imaging is usually needed in assessing congenital heart disease. Apart from Ebstein anomaly, other congenital entities of tricuspid valve such as prolapse and/or retraction can lead to severe tricuspid regurgitation. Due to limitations of 2D TTE in assessing tricuspid valve anatomy, 3D TTE has to be performed, but if it is not enough, 3D TOE can be an option to evaluate mechanism and directly see the orifice of regurgitation in congenital disease of tricuspid valve. Abstract P879 Figure