Normal Tricuspid Annular Dynamics

Study Questions:

Previous studies have shown that tricuspid annulus (TA) enlargement occurs in the septal lateral (SL) direction, a dimension that is difficult to assess using two-dimensional echocardiography (2DE). What is the utility of three-dimensional transthoracic echocardiography (3DE) over 2DE to characterize TA geometry and dynamics using a novel software in healthy volunteers?

Methods:

3DE of the TA from 209 healthy volunteers was analyzed using custom software to measure TA area, perimeter, circularity, and dimensions at various stages of the cardiac cycle.

Results:

There was no correlation between age and TA geometry parameters (r < 0.30). All TA geometry parameters showed significant correlations with body size measures (body surface area [BSA], r = 0.5-0.6; height, r = 0.4-0.5). Women had larger indexed TA perimeter and longer long-axis dimensions compared with men. The longest 3DE TA dimension was significantly longer than diameters measured from both 2DE and 3D multiplanar reconstruction. 3DE TA area, perimeter, and dimensions were largest in late-diastole and smallest at mid-systole/end-systole. Normal tricuspid valve parameters in end-diastole were 8.6 ± 2.0 cm2 for area; 10.5 ± 1.2 cm for perimeter; 36 ± 4 mm and 30 ± 4 mm for longest and shortest dimensions, respectively; and 0.83 ± 0.10 for circularity. 3DE TA area, perimeter, and dimensions correlated with both right atrial and right ventricular volumes, suggesting that both chambers may be determinants of TA size. TA fractional area change was 35 ± 10%. Fractional changes in both perimeter and dimensions were >20%. Computed tomography (CT)- and 3DE-obtained perimeter and area measurements correlated highly (r = 0.91 and 0.94, respectively). CT-derived TA perimeter and area, as expected, were larger than those obtained from 3DE by 1.9 ± 0.7 cm and 3.8 ± 1.7 cm2, respectively.

Conclusions:

3DE allows the assessment of static and dynamic TA dimensions and function, which were found to correlate well with CT. Gender and body size should be considered to identify the reference values of TA dimensions. 2DE underestimates TA dimensions.

Perspective:

This study presents 3DE as a promising imaging modality for tricuspid valve complex assessment. Current guidelines recommend reliance on tricuspid annular anatomical measurements rather than valvular regurgitation severity for clinical decision making; these findings highlight the role of 3DE in such patients. Further refinement in this technology including software development and dissemination will lead to improved understanding and adoption in routine clinical practice.

Clinical Topics: Heart Failure and Cardiomyopathies, Noninvasive Imaging, Valvular Heart Disease, Acute Heart Failure, Computed Tomography, Echocardiography/Ultrasound, Nuclear Imaging

Keywords: Body Size, Body Surface Area, Diagnostic Imaging, Diastole, Echocardiography, Echocardiography, Three-Dimensional, Heart Failure, Heart Valve Diseases, Systole, Tomography, X-Ray Computed, Tricuspid Valve, Tricuspid Valve Insufficiency


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