Tricuspid Valve Disease: Imaging Using Transthoracic Echocardiography

  • Osama I. SolimanEmail author
  • Jackie McGhie
  • Ashraf M. Anwar
  • Mihai Strachinaru
  • Marcel L. Geleijnse
  • Folkert J. ten Cate


Tricuspid valve disease is common but often has less attention than in the left side of the heart. Functional tricuspid regurgitation if left untreated is associated with unfavorable outcome. Moreover, tricuspid valve surgery is often associated with higher complications than for any other surgical valve intervention. Transthoracic echocardiography (TTE) is the gold standard imaging of choice in the assessment of tricuspid valve disease. TTE has many sub modalities such as the M-mode, 2D and 3D modes, the bi-plane mode and the recently introduced iRotate mode. Furthermore, Doppler interrogation of the tricuspid valve as well as blood flow over other cardiac valves, pulmonary, aortic, hepatic venous flow is the mainstay in hemodynamic assessment of patients with tricuspid valve disease. TTE role begins with screening for the presence or absence and type of tricuspid valve disease. Moreover, determination of the etiology, severity of the tricuspid lesion, associated other valvular problems and chamber quantification are part of an imaging protocol/approach, which required for full diagnosis of tricuspid valve disease. Pre-operative and pre-catheter interventional planning can be performed by TTE. Finally, post interventional outcome as well as follow-up is often determined via TTE. In this chapter, we will provide a comprehensive and state-of-the art overview of the use of TTE for the assessment of TV disease. Advantages as well as limitations of each TTE sub modality will be outlined. A perspective on the value of TTE in the era of percutaneous transcatheter TV interventions will also be highlighted.


Echocardiography Transthoracic M-mode Doppler iRotate 2 Dimensional 3 Dimensional Tricuspid Stenosis Regurgitation Severity Surgery Interventions Outcome 

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  1. 1.
    Anwar AM, Geleijnse ML, Soliman OI, McGhie JS, Frowijn R, Nemes A, van den Bosch AE, Galema TW, Ten Cate FJ. Assessment of normal tricuspid valve anatomy in adults by real-time three-dimensional echocardiography. Int J Cardiovasc Imaging. 2007;23:717–24.CrossRefPubMedPubMedCentralGoogle Scholar
  2. 2.
    Lang RM, Badano LP, Tsang W, Adams DH, Agricola E, Buck T, Faletra FF, Franke A, Hung J, de Isla LP, Kamp O, Kasprzak JD, Lancellotti P, Marwick TH, McCulloch ML, Monaghan MJ, Nihoyannopoulos P, Pandian NG, Pellikka PA, Pepi M, Roberson DA, Shernan SK, Shirali GS, Sugeng L, Ten Cate FJ, Vannan MA, Zamorano JL, Zoghbi WA, American Society of Echocardiography, European Association of Echocardiography. EAE/ASE recommendations for image acquisition and display using three-dimensional echocardiography. J Am Soc Echocardiogr. 2012;25:3–46.CrossRefPubMedGoogle Scholar
  3. 3.
    Anwar AM, Geleijnse ML, Ten Cate FJ, Meijboom FJ. Assessment of tricuspid valve annulus size, shape and function using real-time three-dimensional echocardiography. Interact Cardiovasc Thorac Surg. 2006;5:683–7.CrossRefPubMedGoogle Scholar
  4. 4.
    Velayudhan DE, Brown TM, Nanda NC, Patel V, Miller AP, Mehmood F, Rajdev S, Fang L, Frans EE, Vengala S, Madadi P, Yelamanchili P, Baysan O. Quantification of tricuspid regurgitation by live three-dimensional transthoracic echocardiographic measurements of vena contracta area. Echocardiography. 2006;23:793–800.CrossRefPubMedGoogle Scholar
  5. 5.
    Mutlak D, Carasso S, Lessick J, Aronson D, Reisner SA, Agmon Y. Excessive respiratory variation in tricuspid regurgitation systolic velocities in patients with severe tricuspid regurgitation. Eur Heart J Cardiovasc Imaging. 2013;14:957–62.CrossRefPubMedGoogle Scholar
  6. 6.
    Agmon Y, Caspi O. Respiratory variation in tricuspid valve regurgitant orifice: a three-dimensional transthoracic echocardiographic perspective. Eur Heart J Cardiovasc Imaging. 2016;17(10):1188.CrossRefPubMedGoogle Scholar
  7. 7.
    Dreyfus GD, Chan KM. Functional tricuspid regurgitation: a more complex entity than it appears. Heart. 2009;95:868–9.CrossRefPubMedGoogle Scholar
  8. 8.
    Dreyfus GD, Martin RP, Chan KM, Dulguerov F, Alexandrescu C. Functional tricuspid regurgitation: a need to revise our understanding. J Am Coll Cardiol. 2015;65:2331–6.CrossRefPubMedGoogle Scholar
  9. 9.
    Raja SG, Dreyfus GD. Basis for intervention on functional tricuspid regurgitation. Semin Thorac Cardiovasc Surg. 2010;22:79–83.CrossRefPubMedGoogle Scholar
  10. 10.
    Dreyfus J, Durand-Viel G, Raffoul R, Alkhoder S, Hvass U, Radu C, Al-Attar N, Ghodbhane W, Attias D, Nataf P, Vahanian A, Messika-Zeitoun D. Comparison of 2-dimensional, 3-dimensional, and surgical measurements of the tricuspid annulus size: clinical implications. Circ Cardiovasc Imaging. 2015;8:e003241.CrossRefPubMedGoogle Scholar
  11. 11.
    Anwar AM, Soliman OI, Nemes A, van Geuns RJ, Geleijnse ML, Ten Cate FJ. Value of assessment of tricuspid annulus: real-time three-dimensional echocardiography and magnetic resonance imaging. Int J Cardiovasc Imaging. 2007;23:701–5.CrossRefPubMedPubMedCentralGoogle Scholar
  12. 12.
    Anwar AM, Geleijnse ML, Soliman OI, McGhie JS, Nemes A, ten Cate FJ. Evaluation of rheumatic tricuspid valve stenosis by real-time three-dimensional echocardiography. Heart. 2007;93:363–4.CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    Faletra F, La Marchesina U, Bragato R, De Chiara F. Three dimensional transthoracic echocardiography images of tricuspid stenosis. Heart. 2005;91:499.CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    McGhie JS, Menting ME, Vletter WB, Frowijn R, Roos-Hesselink JW, Soliman OI, van der Zwaan HB, Geleijnse ML, van den Bosch AE. A novel 13-segment standardized model for assessment of right ventricular function using two-dimensional iRotate echocardiography. Echocardiography. 2016;33:353–61.CrossRefPubMedGoogle Scholar
  15. 15.
    McGhie JS, Menting ME, Vletter WB, Frowijn R, Roos-Hesselink JW, van der Zwaan HB, Soliman OI, Geleijnse ML, van den Bosch AE. Quantitative assessment of the entire right ventricle from one acoustic window: an attractive approach. Eur Heart J Cardiovasc Imaging. 2016 Aug 7. pii: jew165. [Epub ahead of print].Google Scholar
  16. 16.
    Addetia K, Yamat M, Mediratta A, Medvedofsky D, Patel M, Ferrara P, Mor-Avi V, Lang RM. Comprehensive two-dimensional interrogation of the tricuspid valve using knowledge derived from three-dimensional echocardiography. J Am Soc Echocardiogr. 2016;29:74–82.CrossRefPubMedGoogle Scholar
  17. 17.
    Singh JP, Evans JC, Levy D, Larson MG, Freed LA, Fuller DL, Lehman B, Benjamin EJ. Prevalence and clinical determinants of mitral, tricuspid, and aortic regurgitation (the Framingham Heart Study). Am J Cardiol. 1999;83:897–902.CrossRefPubMedGoogle Scholar
  18. 18.
    Boyaci A, Gokce V, Topaloglu S, Korkmaz S, Goksel S. Outcome of significant functional tricuspid regurgitation late after mitral valve replacement for predominant rheumatic mitral stenosis. Angiology. 2007;58:336–42.CrossRefPubMedGoogle Scholar
  19. 19.
    Porter A, Shapira Y, Wurzel M, Sulkes J, Vaturi M, Adler Y, Sahar G, Sagie A. Tricuspid regurgitation late after mitral valve replacement: clinical and echocardiographic evaluation. J Heart Valve Dis. 1999;8:57–62.PubMedGoogle Scholar
  20. 20.
    Izumi C, Iga K, Konishi T. Progression of isolated tricuspid regurgitation late after mitral valve surgery for rheumatic mitral valve disease. J Heart Valve Dis. 2002;11:353–6.PubMedGoogle Scholar
  21. 21.
    Bruce CJ, Connolly HM. Right-sided valve disease deserves a little more respect. Circulation. 2009;119:2726–34.CrossRefPubMedGoogle Scholar
  22. 22.
    Nath J, Foster E, Heidenreich PA. Impact of tricuspid regurgitation on long-term survival. J Am Coll Cardiol. 2004;43:405–9.CrossRefPubMedGoogle Scholar
  23. 23.
    Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP 3rd, Guyton RA, O'Gara PT, Ruiz CE, Skubas NJ, Sorajja P, Sundt TM 3rd, Thomas JD, American College of Cardiology/American Heart Association Task Force on Practice G. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014;63:2438–88.CrossRefPubMedGoogle Scholar
  24. 24.
    Joint Task Force on the Management of Valvular Heart Disease of the European Society of C, European Association for Cardio-Thoracic S, Vahanian A, Alfieri O, Andreotti F, Antunes MJ, Baron-Esquivias G, Baumgartner H, Borger MA, Carrel TP, De Bonis M, Evangelista A, Falk V, Iung B, Lancellotti P, Pierard L, Price S, Schafers HJ, Schuler G, Stepinska J, Swedberg K, Takkenberg J, Von Oppell UO, Windecker S, Zamorano JL, Zembala M. Guidelines on the management of valvular heart disease (version 2012). Eur Heart J. 2012;33:2451–96.CrossRefGoogle Scholar
  25. 25.
    Tribouilloy CM, Enriquez-Sarano M, Bailey KR, Tajik AJ, Seward JB. Quantification of tricuspid regurgitation by measuring the width of the vena contracta with Doppler color flow imaging: a clinical study. J Am Coll Cardiol. 2000;36:472–8.CrossRefPubMedGoogle Scholar
  26. 26.
    Zoghbi WA, Enriquez-Sarano M, Foster E, Grayburn PA, Kraft CD, Levine RA, Nihoyannopoulos P, Otto CM, Quinones MA, Rakowski H, Stewart WJ, Waggoner A, Weissman NJ, American Society of E. Recommendations for evaluation of the severity of native valvular regurgitation with two-dimensional and Doppler echocardiography. J Am Soc Echocardiogr. 2003;16:777–802.CrossRefPubMedGoogle Scholar
  27. 27.
    Chen TE, Kwon SH, Enriquez-Sarano M, Wong BF, Mankad SV. Three-dimensional color Doppler echocardiographic quantification of tricuspid regurgitation orifice area: comparison with conventional two-dimensional measures. J Am Soc Echocardiogr. 2013;26:1143–52.CrossRefPubMedGoogle Scholar
  28. 28.
    Rodriguez L, Thomas JD, Monterroso V, Weyman AE, Harrigan P, Mueller LN, Levine RA. Validation of the proximal flow convergence method. Calculation of orifice area in patients with mitral stenosis. Circulation. 1993;88:1157–65.CrossRefPubMedGoogle Scholar
  29. 29.
    Rodriguez L, Anconina J, Flachskampf FA, Weyman AE, Levine RA, Thomas JD. Impact of finite orifice size on proximal flow convergence. Implications for Doppler quantification of valvular regurgitation. Circ Res. 1992;70:923–30.CrossRefPubMedGoogle Scholar
  30. 30.
    Sugeng L, Weinert L, Lang RM. Real-time 3-dimensional color Doppler flow of mitral and tricuspid regurgitation: feasibility and initial quantitative comparison with 2-dimensional methods. J Am Soc Echocardiogr. 2007;20:1050–7.CrossRefPubMedGoogle Scholar
  31. 31.
    Mascherbauer J, Maurer G. The forgotten valve: lessons to be learned in tricuspid regurgitation. Eur Heart J. 2010;31:2841–3.CrossRefPubMedGoogle Scholar
  32. 32.
    Topilsky Y, Tribouilloy C, Michelena HI, Pislaru S, Mahoney DW, Enriquez-Sarano M. Pathophysiology of tricuspid regurgitation: quantitative Doppler echocardiographic assessment of respiratory dependence. Circulation. 2010;122:1505–13.CrossRefPubMedGoogle Scholar
  33. 33.
    de Agustin JA, Viliani D, Vieira C, Islas F, Marcos-Alberca P, Gomez de Diego JJ, Nunez-Gil IJ, Almeria C, Rodrigo JL, Luaces M, Garcia-Fernandez MA, Macaya C, Perez de Isla L. Proximal isovelocity surface area by single-beat three-dimensional color Doppler echocardiography applied for tricuspid regurgitation quantification. J Am Soc Echocardiogr. 2013;26:1063–72.CrossRefPubMedGoogle Scholar
  34. 34.
    Quinones MA, Otto CM, Stoddard M, Waggoner A, Zoghbi WA, Doppler Quantification Task Force of the N, Standards Committee of the American Society of E. Recommendations for quantification of Doppler echocardiography: a report from the Doppler Quantification Task Force of the Nomenclature and Standards Committee of the American Society of Echocardiography. J Am Soc Echocardiogr. 2002;15:167–84.CrossRefPubMedGoogle Scholar
  35. 35.
    Fadel BM, Almulla K, Husain A, Dahdouh Z, Di Salvo G, Mohty D. Spectral Doppler of the hepatic veins in tricuspid valve disease. Echocardiography. 2015;32:856–9.CrossRefPubMedGoogle Scholar
  36. 36.
    Kim HK, Kim YJ, Park JS, Kim KH, Kim KB, Ahn H, Sohn DW, Oh BH, Park YB, Choi YS. Determinants of the severity of functional tricuspid regurgitation. Am J Cardiol. 2006;98:236–42.CrossRefPubMedGoogle Scholar
  37. 37.
    Fawzy H, Fukamachi K, Mazer CD, Harrington A, Latter D, Bonneau D, Errett L. Complete mapping of the tricuspid valve apparatus using three-dimensional sonomicrometry. J Thorac Cardiovasc Surg. 2011;141:1037–43.CrossRefPubMedGoogle Scholar
  38. 38.
    Maffessanti F, Gripari P, Pontone G, Andreini D, Bertella E, Mushtaq S, Tamborini G, Fusini L, Pepi M, Caiani EG. Three-dimensional dynamic assessment of tricuspid and mitral annuli using cardiovascular magnetic resonance. Eur Heart J Cardiovasc Imaging. 2013;14:986–95.CrossRefPubMedGoogle Scholar
  39. 39.
    Ton-Nu TT, Levine RA, Handschumacher MD, Dorer DJ, Yosefy C, Fan D, Hua L, Jiang L, Hung J. Geometric determinants of functional tricuspid regurgitation: insights from 3-dimensional echocardiography. Circulation. 2006;114:143–9.CrossRefPubMedGoogle Scholar
  40. 40.
    Zoghbi WA, Adams D, Bonow RO, Enriquez-Sarano M, Foster E, Grayburn PA, Hahn RT, Han Y, Hung J, Lang RM, Little SH, Shah DJ, Shernan S, Thavendiranathan P, Thomas JD, Weissman NJ. Recommendations for Noninvasive Evaluation of Native Valvular Regurgitation. J Am Soc Echocardiogr. 2017;30(4):303–71.Google Scholar
  41. 41.
    Lawrence G. Rudski, Wyman W. Lai, Jonathan Afilalo, Lanqi Hua, Mark D. Handschumacher, Krishnaswamy Chandrasekaran, Scott D. Solomon, Eric K. Louie, Nelson B. Schiller, (2010) Guidelines for the Echocardiographic Assessment of the Right Heart in Adults: A Report from the American Society of Echocardiography. JJ Am Soc Echocardiogr. 23(7):685–713Google Scholar

Copyright information

© Springer International Publishing AG 2018

Authors and Affiliations

  • Osama I. Soliman
    • 1
    Email author
  • Jackie McGhie
    • 2
  • Ashraf M. Anwar
    • 3
  • Mihai Strachinaru
    • 2
  • Marcel L. Geleijnse
    • 2
  • Folkert J. ten Cate
    • 2
  1. 1.Department of CardiologyThoraxcenter, Erasmus MC: University Medical Center RotterdamRotterdamThe Netherlands
  2. 2.Thoraxcenter, Erasmus University Medical CenterRotterdamThe Netherlands
  3. 3.Cardiology Department, Faculty of MedicineAl-Azhar UniversityCairoEgypt

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