Anatomy and echocardiography of the normal and abnormal tricuspid valve

Abstract

Perhaps because it guards the inlet to the lesser circulation, the morphologically tricuspid valve has received less attention in terms of its anatomy than the well-explored mitral valve, which will receive attention in a subsequent review in this supplement.1 As we will show in our initial review, nonetheless, the approach to morphological analysis is the same for both valves, irrespective of whether the specific morphology is displayed in the autopsy room or the echocardiographic laboratory. It is essential that the valve be analysed so as to reveal the precise structure of each if its components – the so-called valvar complex.2 Equally important, in the current era, with the burgeoning use of three-dimensional displays that place the heart firmly within the context of the body, it is essential that the components of the valve be described as seen relative to the bodily axis,3 rather than following the present custom of describing the heart as though it is removed from the body and positioned on its own apex.

Two-Dimensional Transesophageal Echocardiographic Imaging of the Tricuspid Valve

“…First, TV imaging has received less literature attention compared with the left-sided valves. 1 Second, it can be difficult to obtain satisfactory 2-dimensional (2D) views of the TV using TEE in some patients. 2 Imaging difficulties relate to the relative distance between the valve and transducer in midesophageal (ME) views and individual variation in leaflet size.…”

“…The commissures between the 3 leaflets are less distinct compared with other valves (Video 1, see Supplemental Digital Content 1, http://links.lww.com/AA/A347). In fact, Martinez et al 1 refer to a "skirt" of leaflet tissue encircling the annulus. Because the septal leaflet is anchored by the fibrous trigones, tricuspid annular dilation occurs primarily along the attachments of the anterior and posterior leaflets.…”

“…In addition, direct chordal attachments between the ventricular septum and septal leaflet represent one of the most constant features of TV anatomy. 1 There are chordal attachments from the anterior papillary muscle to the anterior and posterior leaflets. The posterior papillary muscle provides chordae to the posterior and septal leaflets, whereas the septal papillary muscle provides chordae to the septal and anterior leaflets.…”

Ebstein's anomaly of the tricuspid valve: from fetus to adult

“…In the apical four chamber view, the excessive apical displacement with regard to the hinge point allows the diagnosis of Ebstein’s anomaly. An apical displacement of the septal tricuspid valve leaflet from the insertion of the anterior mitral valve leaflets >8 mm/m2 body surface area distinguishes Ebstein’s malformation from other lesions with tricuspid regurgitation or right heart dilatation. This displacement into the right ventricular apex mainly involves the septal and posterior leaflets and so can be mistaken for right ventricular trabeculations.…”

Imaging the right ventricle

“…Anatomical connections, ventricular morphology and valve structure and function are well established using standard 2D transthoracic and transoesophageal views 13. Right heart haemodynamics can be routinely evaluated by standard echocardiographic modes 9…”