Tricuspid valve

 

Anatomy

The tricuspid valve ensures that there is no backflow from the right ventricle to the right atrium during systole. The tricuspid valve, as its Latin name suggests, consists of three leaflets: the septal (S), the anterior (A) and posterior (P) leaflets, of which the anterior leaflet is the largest. The tricuspid valve is distinguished not only by the number of valve leaflets as compared to mitral valve, but also by its method of attachment. The mitral valve chordae attach to only two papillary muscle heads where the chordae of tricuspid attach to much more muscle heads and also directly into the interventricular septum. The valve is located slightly more towards the apex as compared to the mitral valve.

Cross sectiom of heart valves

 

 

Regurgitation

Quantification of tricuspid regurgitation

ParameterMildModerateSevere
RV/RA/IVCnormalnormal/dilateddilated
Hepatic vein flowsyst. dominantsyst. decreasesyst. flow reversal
Vena contracta (mm)<7>7
PISA (cm²)< 0.60.6 - 0.9> 0.9
Density CW signallichtdensdens
Contour CW signalparabolicvariabletriangular
TR jet / RA area* (%)< 2020 - 34> 35
* The size of the color-doppler surface in right atrium is only a rough impression.

Echocardiographic criteria for the definition of severe tricuspid valve regurgitation: an integrative approuch.

ParameterCriteria
Qualitative
Valve morphologyAbnormal/flail/large coaptation defect
Colour flow regurgitant jetVery large central jet or eccentric wall impinging jet *
CW signal of regurgitant jetDense/triangular with early peaking (peak <2 m/s in massive TR)
Semiquantitative
Vena contracta width (mm)≥ 7 *
Upstream vein flowSystolic hepatic vein flow reversal
InflowE-wave dominant ≥ 1 m/s **
PISA radius (mm)> 9 ***
Quantative
EROA (mm²)≥ 40
Regugitant volume (mL/beat)≥ 45
Enlargement of cardiac chamber/vesselsRV, RA, IVC
* At Nyquist limit of 50-60 cm/s.
** In the absence of other causes of elevated LA pressure
*** Baseline Nyquist limit shift of 28 cm/s.

TR vena contracta

 

Causes of tricuspid regurgitation

Functional TRSecundary TR
Disorders of the right ventricle: RV infarction, dilated cardiomyopathyEbstein anomaly
Secondary to pulmonary hypertension, for example: cor pulmonale, pulmonary embolism, or primary.Infective Endocarditis
Mitral stenosis or mitral regurgitationTrauma
Left-right shunt, such as an atrial septal defect or a ventricular septal defectRheumatic fever
Eisenmenger syndrome (rare)Carcinoid
Pulmonary stenosisPapillary muscle disorders
HyperthyroidismConnective tissue diseases such as Marfan Syndrome.
Non-infectious endocarditis, such as SLE or rheumatoid arthritis
Damage from the electrode of a pacemaker or ICD

 

 

Eur J Echocardiogr. 2010 May;11(4):307-32

European Heart Journal (2017) 00, 1?53

 

 

 

Stenosis

Tricuspid valve stenosis is usually caused by rheumatic fever which mostly occurs during childhood. The rarely reported second causes of tricuspid valve stenosis include tumour obstruction, carcinoid disease and obstructed tricuspid valve prosthesis.

Quantification of tricuspid stenosis

ParameterMildModerateSevere
TVA (cm²)< 1
PHT (ms)> 190
PGmean (mmHg)> 5
VTI (cm)> 60

 

 

Eur J Echocardiogr. 2009 Jan;10(1):1-25