Assessment of tricuspid valve regurgitation using 2d and 3d echocardiography: a monocentric comparative study of transthoracic and transesophageal approaches for pre-intervention screening

Abstract Background Historically, isolated tricuspid valve surgery for significative tricuspid regurgitation has been associated with high in-hospital mortality rates. Consequently, the early success of transcatheter repair and replacement techniques has expanded access to relatively low-risk treatment options. However, it remains unclear whether transthoracic echocardiography (TTE) alone is sufficient for screening patients undergoing transcatheter or surgical interventions, or if transesophageal echocardiography (TEE) is always required. Aim The aim of this study is to compare the accuracy of 2D and 3D tricuspid valve assessments using TTE versus TEE in screening patients eligible for surgical or transcatheter interventions for tricuspid regurgitation (TR). Methods Consecutive patients diagnosed with symptomatic and significant TR were prospectively enrolled. Each patient underwent both 2D/3D TTE and 2D/3D TEE on the same day. Right ventricular (RV) size and function were assessed using 2D imaging from the apical RV-focused view (TTE) and the mid-esophageal four-chamber view (TEE) at end-diastole. 3D reconstructions were used to evaluate tricuspid annular dimensions (diameters, area, perimeter), leaflet morphology, valve orifice area, and coaptation parameters. The coaptation gap was measured from the transgastric view (TEE) and 3D reconstructions (TTE). The GLIDE score was calculated for both modalities. All echocardiographic exams were acquired and analyzed by a single expert operator in a blinded fashion. To assess intra- and inter-observer variability, 30 studies (15 TTE and 15 TEE) were randomly selected for double-blind re-analysis by the same operator. These were then independently re-evaluated by a second experienced operator. Results The study population consisted of 42 patients (25 males, 17 females) with a median age of 79 years. Among them, 52.3% had severe TR, 42.8% had massive TR, and 4.7% had torrential TR. No statistically significant differences were observed between TTE and TEE in the evaluation of TR severity, RV size and function, annular dimensions, coaptation gap, or GLIDE score (p 0.05). However, leaflet number was more accurately assessed by TEE (p 0.001). Intra- and inter-operator variability for the selected 2D/3D parameters showed excellent agreement. (Table 1 and 2) Conclusions TTE is a reliable tool for the initial screening of patients with significant TR who are candidates for surgical or transcatheter intervention. However, TEE provides superior visualization of leaflet morphology and should be performed in patients with favorable TTE findings. These results are particularly relevant for elderly and frail patients, who may be spared a transesophageal examination if TTE findings are already unfavorable.Table 1 Table 2