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A detailed transesophageal echocardiographic (TEE) examination of the right-sided heart valves can provide accurate diagnosis of valvular diseases; define anatomic, functional, and perivalvular abnormalities; and guide appropriate management. Integration of this information with the evaluation of the cardiac chambers is necessary to assess the degree of the pathology and determine its impact on cardiac function. In a review of 1918 cases undergoing intraoperative TEE prior to cardiac surgery, discrepant findings at the time of surgical inspection were present in only 48 patients, of which five involved the tricuspid and pulmonic valves.1 Therefore, this modality should yield adequate diagnostic accuracy when the exam is conducted appropriately. This chapter discusses the main pathologies involving the tricuspid and pulmonic valves leading to regurgitation and/or stenosis, and their assessment by two-dimensional TEE (Table 10–1). Even with the advent of three-dimensional matrix array probes allowing the acquisition of real-time images, optimal visualization of the tricuspid and pulmonary valves is seldom feasible2; therefore, their three-dimensional evaluation will depend on future improvements of this technology.
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Relevant Anatomical Landmarks
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The tricuspid valve, the largest of the four cardiac valves, lies slightly below the plane of the mitral valve, and is in close proximity to the aortic valve. The three leaflets of the tricuspid valve are named anterior, posterior (inferior), and septal (medial) based on their relative positions (Figure 10–1). The septal leaflet's insertion point at the septum is more apically displaced than that of the anterior mitral leaflet. The two major papillary muscles, the anterior and posterior, are located on the corresponding walls of the right ventricle. Through their chordae tendineae, they attach to the anterior and posterior cusps, and the posterior and septal cusps, respectively. When present, a smaller septal papillary muscle attaches to the septal and anterior cusps.3 The three leaflets of the valve can be imaged using different angulations of the imaging plane together with flexion of the probe tip (see Figure 10–1).
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