Real time Three-dimensional Echocardiography in Tricuspid Valve Diseases.

The tricuspid valve is a forgotten valve It has multi-component complex structure. The tricuspid valve is composed of three leaflets (anterior, posterior and septal) attached to a fibrous annulus.The three-dimensional shape of the tricuspid annulus is complex and does not conform to a flat ring .Tricuspid regurgitation is the most common pathology affecting the tricuspid valve. An understanding of the pathological process underlying tricuspid regurgitation is necessary to determine the optimal management strategy. Usually tricuspid regurgitation is secondary to left-sided valvular pathology (mostly mitral valve disease) with pulmonary hypertension and right ventricular dilatation. Because the tricuspid annulus is a component of the right ventricle it will dilate also. Unfortunatelytricuspid valve evaluation continues to be a major problem in the surgical decision making process. Unlike the aortic and mitral valve it is not possible to visualize all tricuspid valve cusps simultaneously in one cross-sectional view by standard transthoracic two- dimensional echocardiography During transesophageal 2D Echo small changes in transducer angle, probe position and rotation may bring to light some additional tricuspid valve details .However, because of the position of the tricuspid valve in the far field in relation to probe, transesophageal 2DEcho can still only provide limited information and can also not visualize all tricuspid cusps simultaneously. At the time of surgery the decision to repair the tricuspid valve may be changed due to discrepant tricuspid annular diameter findings between pre-operative two-dimensional transthoracic or transesophageal echocardiography and direct surgical visualization . These unsatisfactory results call for a reappraisal of surgical techniques for TR that in the past might have been based on an incomplete knowledge of tricuspid annulus geometry. Tricuspid vavle is affected by a variety of congenital and acquired diseases Rheumatic heart disease causes tricuspid valve stenosis in up to 8% of patients. Unfortunately, tricuspid valve stenosis is easily missed at clinical examina tion except in advanced cases when a high degree of clinical suspicion exists. Undetected and thus uncorrected tricuspid valve stenosis may lead to postoperative low cardiac output despite successful relief of leftsided valve disease and carries a high mortality and morbidity. AIM OF THE STUDY: The study aims at utilizing Real time three-dimensional transthoracic echocardiography (RT3DE) technique for a. qualitative and quantitative analysis of tricuspid valve in both normal and dieased states b. comprehensive assessment of individual leaflets of tricuspid valve commisures ,leaflets ,valve area and annulus in normal individuals c. detailed analysis of tricuspid annulus, commisures, valve area and leaflets in patients with functional regurgitation. d. assessment with descriptive tricuspid valve morphology for each tricuspid valve leaflets and each tricuspid valve commissure and tricuspid valve area in patients with rheumatic tricuspid valve stenosis e. comprehensive assessment of individual leaflets of tricuspid valve and annulus in patients with organic tricuspid valve diseases like ebsteins anomaly and infective endocarditis The study aims to compare the findings between 2D TTE and RT3D echo. CONCLUSIONS: 1. Real time three dimensional echocardiography of the tricuspid valve can be performed in addition to routine two dimensional echocardiography within a reasonable time and with high assessability 2. The Tricuspid annulus in three dimensional echocardiography is an oval structure with a major and a minor diameter 3. Two dimensional Transthoraxic echo underestimates tricuspid annular diameter when compared to three dimensional echo , regardless whether it is measured from the apical 4-chamber or parasternal short axis view This may have important implications in the tricuspid valve surgical decision-making processes. 4. Real time three dimensional echocardiography provides unique tricuspid valve measurements such as Tricuspid valve area which can be used to access the severity of tricuspid stenosis 5. Commissural width at the time of maximal tricuspid valve opening can be measured. This distance between the tricuspid valve commissures during diastole may be a new indicator of tricuspid valve stenosis severity 6. Real time three dimensional echocardiography provides an comprehensive assessment of Ebstein anomaly,the extent of displacement of posterior leaflet and the extent of tethering and would be an valuable supplement to 2D echo 7. By combining all information obtained by 2D and RT3DE, the diagnostic and therapeutic decision-making process regarding the tricuspid valve may be facilitated