The Advantages of Live/Real Time Three‐Dimensional Transesophageal Echocardiography in the Assessment of Tricuspid Valve Infective Endocarditis

Abstract

Currently, tricuspid valve infective endocarditis (TVIE) is encountered in daily clinical practice more frequently due to the increasing prevalence of illicit intravenous drug use and the implantation of intracardiac devices. In this study, we compared findings from intra-operative live/real time three-dimensional transesophageal echocardiograms (3DTEE) and two-dimensional transesophageal echocardiograms (2DTEE) of 10 patients who underwent surgery for native tricuspid valve (TV) endocarditis. Unlike 2DTEE, 3DTEE allowed en face visualization of the 3 TV leaflets from both, atrial and ventricular aspects, in 9 of the 10 cases. In the remaining patient, in whom 3DTEE could not identify all 3 leaflets en face, the TV was found essentially destroyed at surgery. Using 3DTEE, the number of vegetations was accurately reported when compared with the surgical record. Furthermore, the orientation of each vegetation was the same as noted in the surgical findings. 2DTEE missed the identification of vegetations in 5 patients. The attachment site of vegetations to the TV were also not characterized by 2DTEE in 5 patients. In all 10 cases, 3DTEE characterized the vegetations more accurately with larger dimensions, including those in the azimuthal axis, and volumes. In addition, a perivalvular abscess that lead to surgical intervention was identified by 3DTEE, however, missed by 2DTEE. In conclusion, 3DTEE allows en face visualization of the TV apparatus permitting accurate description of the number and dimensions of vegetations identified by our surgical standard, which ultimately informs patients' prognosis and dictates the timing and planning for surgical intervention. Its use should be in conjunction with 2DTEE when evaluating TVIE.

Evaluation of vegetation size and its relationship with septic pulmonary embolism in tricuspid valve infective endocarditis: A real time 3DTEE study

“…However, this study evaluated only vegetations in left‐sided valves. Sungur and colleagues compared 3DTEE and 2DTEE in 10 patients with TVIE and concluded that 3DTEE was superior in determining the overall presence and exact site of TV vegetations. However, no comparison of vegetation size between 3DTEE and 2DTEE was performed in this previous study.…”

Novel 3D versus traditional transesophageal echocardiography techniques: Defining differences in the diagnosis of infective endocarditis

“…Given that the tricuspid valve (TV) is anteriorly located, 3D TOE should yield a more accurate assessment than 2D TOE. Two studies 28,37 and a few case reports 38,39 assessed the potential advantages of 3D TOE in patients with the TV or cardiac device-related IE. One investigation showed that in 90% of patients, 3D TOE enabled the comprehensive examining of all TV leaflets and the subvalvular apparatus, while 2D TOE failed to detect vegetation in 50% of the patients.…”

Assessment of tricuspid valve by two‐ and three‐dimensional echocardiography with special reference to percutaneous repair and prosthetic valve implantation procedures

“…42,43 Other structural defects can also now be adequately identified, leading to mechanisms of TR being easily elucidated. Visualization of the TV leaflets en face in B-mode in the short axis using 3DTTE also provides the assessment of the exact size, shape, and size of TV leaflet defects, which may be congenital 47 or acquired as is the case in endocarditis, [48][49][50][51] which may also result in loss of leaflet tissue. One of the major advantages of 3DTTE over 2D imaging is the ability to reliably assess the shape and size of the TR VC, through which regurgitation can be visualized going into the RA.…”

“…This makes 3DTTE not only more accurate but also simpler to use than 2DTTE in quantitative assessment of the severity of TR. Visualization of the TV leaflets en face in B-mode in the short axis using 3DTTE also provides the assessment of the exact size, shape, and size of TV leaflet defects, which may be congenital 47 or acquired as is the case in endocarditis, [48][49][50][51] which may also result in loss of leaflet tissue. In patients with a dilated TVA or RV, the size of the TV leaflet area which does not coapt and the extent of tethering and displacement of TV leaflets into the RV may also be evaluated.…”