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

Figures

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  FIGURE 1. Three-dimensional assessment of the right ventricle and right atrium using transthoracic echocardiography (a). Evaluation of the subvalvular apparatus using transthoracic three-dimensional dataset showing tricuspid valve leaflets, chordae, papillary muscles and the moderator band (b). Three-dimensional echocardiographic display of the tricuspid valve form the atrial perspective (c) and ventricular perspective (d). AL, anterior leaflet; AV, aortic valve; LA, left atrium; LV, left ventricle; MB, moderator band; MV, mitral valve; PL, posterior leaflet; PMs, papillary muscles; RA, right atrium; RV, right ventricle; RVOT, right ventricular outflow tract; SL, septal leaflet; TV, tricuspid valve.

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  FIGURE 2. A quadricuspid tricuspid valve showing the presence of two distinc posterior leaflets (a). Prolapse of the anterior leaflet of the tricuspid valve (b). Pacemaker lead impingement on the posterior leaflet in a patient with tricuspid regirgitation (c). Coapation gap defect at end systole in a patient with severe tricuspid regurgitation (d). AL, anterior leaflet; PL, posterior leaflet; SL, septal leaflet.

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  FIGURE 3. Cardiac computed tomography assessment of the tricuspid valve, right ventricle, chordae (dashed red arrow) and subvalvular apparatus (red arrows), using an inflow-outflow right ventricular view (a) and a 4-chamber view (b). Tomographic reconstruction of the tricuspid annulus with measurement of annular perimeter (c; courtesy of Dr Giuseppe Muscogiuri, Centro Cardiologico Monzino IRCCS, Milan, Italy). Dedicated software analysis providing three-dimensional reconstruction of the tricuspid annulus (red) and measurement of circumference, area and diameters using cardiac computed tomography datasets (d, e; courtesy of Pie Medical Imaging, The Netherlands); identification of commissures is provided by the software (septal-anterior commissure, dashed pink circle; antero-posterior commissure, light blue dashed circle; septal-posterior commissure, green dashed circle). Localization of surrounding structure by dedicated tricuspid valve software using computed tomography derived virtual angio, providing localization of the aortic valve and identification of the right coronary artery; distance between the tricuspid annulus and the right coronary artery is automatically measured by the…

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  FIGURE 4. Assessment of the tricuspid valve leaflets (dashed red arrows), chordae and papillary muscles (red arrows) using 4-chamber view (a), right ventricular 2-chamber view (b) and right ventricular inflow-outflow view by cardiac magnetic resonance in a patient with Ebstein disease (c). Tomographic reconstruction of tricuspid annular perimeter using dedicated short axis acquisition (d). Assessment of the right ventricular volume and function by direct tracing of the endocardial volume (e, f). RA, right atrium; RV, right ventricle; RVOT, right ventricular outflow tract; TA, tricuspid annulus.

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  FIGURE 5. Panel A. Three-dimensional assessment of the tricuspid annulus using multiplanar reconstruction analysis. Orthogonal planes are adjusted at end-diastole in order to cross the tricuspid valve hinge points using an apical right ventricular 2-chamber (a) and 4-chamber (b) views. Measurement of tricuspid annular perimeter, area and diameters are obtained using the axial plane (c). Panel B. Semi-automated analysis of the tricuspid valve using dedicated software (GE Healthcare, Vingmed, Horten, Norway). After initialization of anatomical references by the reader, the software displays the three-dimensional reconstruction of the tricuspid valve (a) and tricuspid annulus (e). The reader can double check and edit using orthogonal planes (b–d). Measurement of tenting height and volume and tricuspid annular circumference, area, diameters and sphericity index are automatically provided.

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  FIGURE 6. Measurement of three-dimensional vena contracta by transthoracic echocardiography in a patient with functional tricuspid regurgitation (a). Measurement of three-dimensional effective regurgitant orifice area by transthoracic echocardiography in a patient with severe tricuspid regurgitation (b). Quantification of tricuspid regurgitant volume and fraction using cardiac magnetic resonance (c). Regurgitant volume is derived by the difference between the right ventricular stroke volume (yellow) and the forward pulmonary valve stroke volume (red). Assessment of tricuspid regurgitation (orange arrows) using cardiac magnetic resonance 4-D flow images with flow velocity encoded in all directions (d; courtesy of Dr Giuseppe Muscogiuri, Centro Cardiologico Monzino IRCCS, Milan, Italy). PA, pulmonary artery; PV, pulmonary valve; TV, tricuspid valve.

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  FIGURE 7. Example of fusion imaging during transcatheter procedure showing transesophageal echocardiographic bicaval view (a, bottom) superimposed on fluoroscopic images (a, top; courtesy of Prof. Jose L. Zamorano, University Hospital Ramon y Cajal, Madrid, Spain). Three-dimensional printing of a normal tricuspid valve (b, left) and a remodeled tricuspid valve (b, right) showing tricuspid annular dilatation and tethering of the leaflets.