3-Dimensional Echocardiography in Transcatheter Tricuspid Valve Interventions

Stamatios Lerakis,


Director of Imaging for Structural and Valve Interventions for the Mount Sinai Health System

Structural Imaging Fellow, Division of Cardiology, Icahn School of Medicine at Mount Sinai


Richard Ro,

The tricuspid valve has an intricate configuration with its function dependent on the synchronized coordination of its various component.1 The occurrence of significant tricuspid regurgitation (TR) because of the dysfunction of the valve apparatus or its surrounding structures is linked with dismal clinical outcomes.2,3 The rapid emergence of transcatheter procedures, which are currently being actively investigated, can offer a non-surgical treatment pathway in the management of severe tricuspid regurgitation.4 Three-dimensional (3D) echocardiography plays an important role in the initial diagnosis and eventual interventional procedural guidance for these patients.

In the transthoracic exam, 3D images may be beneficial and informative given the anterior location of the right–sided cardiac structures in the chest, allowing for simultaneous visualization and identification of all three tricuspid leaflets and etiology of regurgitation. The commissure between the anterior and septal leaflets is generally close in proximity to the non-coronary cusp of aortic valve, and the coronary sinus is near the commissure between the septal and posterior leaflet. These landmarks, in addition to the interventricular septum and aortic valve, can aid in identifying each individual leaflet. Transesophageal echocardiography is then performed in these patients. 3D imaging in the midesophageal and transgastric views while focusing on the tricuspid valve should be attempted if the two-dimensional images are of sufficient quality. In our experience, the bicaval view in full volume mode is particularly useful to view the tricuspid valve en-face in relation to the interatrial septum and aortic valve, which aids in the identification of the leaflets. Color Doppler should be applied to all 3D images to identify the origin and directionality of the regurgitant jet. (Figure 1)

During transcatheter intervention of the tricuspid valve, transesophageal echocardiography is primarily used, although intracardiac echocardiography can be used in more difficult cases. A combination of 2D and 3D imaging is used for clip steering and navigation, appropriate clip positioning between the two targeted tricuspid leaflets, confirmation of adequate leaflet grasping, and subsequent reduction of tricuspid regurgitation.

Several transcatheter devices are currently undergoing investigation for severe TR in a number of clinical trials.4,5 A set of standardized and reproducible multimodality imaging algorithms, consisting of computed tomography, echocardiography with transthoracic (TTE) and transesophageal (TEE) approaches, that can be used to image the anatomical and functional nature of the tricuspid valve, as well for intra-procedural device navigation, will ultimately be necessary as transcatheter treatment of TR continues to expand.6

Figure 1:

A. Transesophageal echocardiography with full volume imaging from the midesophageal bicaval view with corresponding color Doppler below. The anterior (A), posterior (P), and septal (S) leaflets are shown, as well as the aortic valve (AV).

B. This 3D TEE view at the same echocardiographic window is once again noted with leaflet identification using surrounding anatomical landmarks.

C. In a 3D image from the transgastric view on TEE, the three leaflets can again be clearly identified including the aortic valve (AV). Corresponding color Doppler below shows the tricuspid regurgitant jet (orange), as well as aortic outflow jet (blue).