Tricuspid valve (Echocardiography) (2023)

Va

Aliasing velocity

• Manually set value on the echocardiography machine.
• It´s used to calculate: EROA.
• Nyquist limit: 50-70cm/s
• Baseline is shifted in the direction of tricuspid regurgitation jet to 30-40cm/s.
• Aliasing occurs: If the blood flow from the probe (blue) exceeds the Va speed (38.5cm/s).

VCW

Vena contracta width

• Narrowest portion of jet as emerges from tricuspid orifice.
• Vena contracta is diameter of EROA (Effective Regurgitant Orifice Area).
• A4C (RV focused)
• Zoom mode (focused on tricuspid valve).
• Color doppler
• Nyquist limit (Aliasing velocity): 50-70cm/s

PISAr

Proximal isovelocity surface area radius

• The radius of PISA is measured from the surface of the hemisphere to the narrowest portion of jet (Vena contracta).
• Vena contracta is narrowest portion of jet as emerges from tricuspid orifice.
• The flow convergence zone is the zone of increased flow velocity before the regurgitant orifice.
• It´s used to calculate: EROA.
• A4C (RV focused)
• Zoom mode (focused on tricuspid valve)
• Mid-systole (ECG: The beginning of T wave).
• Color doppler
• Nyquist limit (Aliasing velocity): 30-40cm/s

Vmax TR

Peak tricuspidal regurgitation velocity

• It´s used to calculate: EROA
• A4C (RV focused)
• Systole (ECG: R wave - The end of T wave).
• CW doppler
• Place the cursor between tricuspid leaflet tips.
• Color doppler (helps with blood flow identification).

EROA

Effective regurgitant orifice area

• EROA = 2π x PISAr² x Va / Vmax TR
• Is the narrowest area of tricuspid regurgitation flow.
• It´s used to calculate: RegVol_TR

VTI TR

Velocity time integral of tricuspidal regurgitant jet

• It´s used to calculate: RegVol_TR
• A4C (RV focused)
• Systole (ECG: R wave - The end of T wave)
• CW doppler
• Place the cursor between tricuspid leaflet tips.
• Trace along the edge of the modal velocity to measure the area under the curve.

RegVol_TR

Regurgitant volume of tricuspidal regurgitation

• RegVol_TR = EROA x VTI TR
• Regurgitant volume of tricuspidal regurgitation.

RegJet_{soft density}

Regurgitant jet soft density

• Density and contour of regurgitant jet
• Density is proportional to the number of red blood cells reflecting the signal.
• A4C (RV focused)
• Zoom mode (focused on tricuspid valve)
• Systole (ECG: R wave - The end of T wave)
• CW doppler
• Soft density suggests mild tricuspid regurgitation.

RegJet_{hard density}

Regurgitant jet hard density

• Density and contour of regurgitant jet.
• Density is proportional to the number of red blood cells reflecting the signal.
• A4C (RV focused)
• Systole (ECG: R wave - The end of T wave)
• CW doppler
• Hard density suggests severe tricuspid regurgitation.

A wave_dominant

Dominant tricuspidal A wave (A wave > E wave)

• A4C (RV focused).
• Late-diastole (ECG: Right after P wave)
• PW doppler.
• Sample volume between tricuspid leaflet tips.
• Suggest mild tricuspid regurgitation.

RA major

Right atrium major axis dimension

• Length of righ atrium
• A4C (RV focused).
• End-systole (ECG: The end of T wave).
• Length from center of valve annulus to center of superior RA wall
• Parallel to intraatrial septum.

RVD1_basal

Right ventricular basal diameter at end-diastole

• RVD1 represents the RV’s widest diameter.
• A4C (RV focused).
• End-diastole (ECG: R wave).
• It´s measured just above the tricuspid annulus.

TV_annulus

Tricuspid valve annulus diameter

• A4C (RV focused)
• Zoom mode (focused on tricuspid valve)
• End-diastole (ECG: R wave)
• The dilated tricuspid annulus suggests severe tricuspid regurgitation.

RegJet_area

Regurgitation jet area

• It´s used to calculate: RegJet/RA area
• A4C (RV focused)
• Zoom mode (focused on tricuspid valve)
• Systole (ECG: R wave - The end of T wave)
• Color doppler
• Nyquist limit (Aliasing velocity): 50-70cm/s

RA area

Right atrial area

• It´s used to calculate: RegJet/RA area
• A4C (RV focused)
• Zoom mode (focused on tricuspid valve)
• End-systole (ECG: The end of T wave).
• Color doppler
• Nyquist limit (Aliasing velocity): 50-70cm/s

RegJet/RA area

Ratio RegJet_area / RA area

• RegJet/RA area = RegJet_area / RA area x 100
• Ratio area of the jet to the right atrium area.

HV_{reversal flow}

Hepatic vein reversal flow

• Hepatic vein reversal flow during systole
• SC window (Hepatic vein)
• Systole (ECG: R wave - The end of T wave)
• PW doppler
• Sample volume from hepatal vein.
• Suggests severe tricuspid regurgitation

HV_{forward flow}

Hepatic vein forward flow

• Dominant systolic flow (nonreversal, to the VCI) in hepatic vein during systole.
• SC window (Hepatic vein)
• Systole (ECG: R wave - The end of T wave)
• PW doppler
• Sample volume from hepatal vein.
• Suggests mild tricuspid regurgitation

SV_PV

Stroke volume of pulmonary valve

• SV_PV = CSA_RVOT x VTI_RVOT
• It´s used to calculate: TrVA
• Stroke volume of pulmonary valve is the same as stroke volume of tricuspid valve.
• If no tricuspid regurgitation is present
• Calculate it in the top menu: PV

VTI TrV

Velocity time integral of tricuspid valve (inflow)

• It´s used to calculate: TrVA
• A4C (RV focused)
• Diastole (ECG: The end of T wave - R wave)
• CW doppler
• Place the cursor in the middle of tricuspid valve.
• Trace along the edge of the modal velocity to measure the area under the curve.

TrVA

Tricuspid valve area (continuity equation)

• TrVA = SV_PV / VTI TrV
• TrVA is underestimated if moderate or severe tricuspid regurgitation is present.

meanPG TrV

Mean pressure gradient tricuspidal valve

• A4C (RV focused)
• Diastole (ECG: The end of T wave - R wave)
• CW doppler
• Place the cursor in the middle of tricuspid valve.
• Trace along the edge of the modal velocity (inflow) to measure the area under the curve.

PHT TrV

Pressure half time of tricuspidal valve

• Pressure half-time (PHT) is defined as the time interval in milliseconds between the maximum gradient and the time point where the gradient is half the maximum initial value.
• A4C (RV focused)
• Diastole (ECG: The end of T wave - R wave)
• CW doppler
• Place the cursor in the middle of tricuspid valve.
• PHT is obtained by tracing the deceleration slope.

IVC_diameter

Inferior vena cava diameter

• Maxiumum inferior vena cava diameter.
• SC window (long axis IVC).
• Measured perpendicular to the long axis of the IVC at end-expiration.
• Just proximal to the junction of the hepatic veins that lie
• approximately 1-3cm proximal to the ostium of the right atrium.

References:

Recommendations for Cardiac Chamber Quantification by Echocardiography in Adults: An Update from the ASE and EACVI (2015)

Recommendations for the Evaluation of LV Diastolic Function by Echocardiography: An Update from the ASE and EACVI (2016)

Recommendations on the use of echocardiography in adult hypertension: a report from the EACVI and the ASE (2015)

Recommendations on the Echocardiographic Assessment of Aortic Valve Stenosis: A Focused Update from the EACVI and the ASE (2017)

ASE Recommendations for Noninvasive Evaluation of Native Valvular Regurgitation (2017)

Guidelines for performing a comprehensive TTE examination in adults: Recommendations from the ASE (2018)

Guidelines for the Echocardiographic Assessment of the Right Heart in Adults: ASE, EACVI, ESC, CSE (2010)

Guidelines for the diagnosis and management of acute pulmonary embolism ESC, ERS (2019)

Echocardiography in aortic diseases: EAE recommendations for clinical practice (2010)

Echocardiographic assessment of valve stenosis: EAE/ASE recommendations for clinical practice (2009)

ESSENTIAL ECHOCARDIOGRAPHY A Companion to Braunwald’s Heart Disease

Coronary Artery Territories (Echocardiography Illustrated Book 4)

Regurgitation

Stenosis