Reply to "A Primer on Three-Dimensional Transthoracic Echocardiographic Imaging of the Tricuspid Valve".

Reply:

Dr. Jankowski and Dr. Narang nicely advocate for additional three-dimensional (3D) transthoracic echocardiography (TTE) in the evaluation of tricuspid valve disease both with and without intracardiac leads. The authors are right about this approach, which can be obtained with the tips recommended. Even though we are proficient in both modalities, our experience from everyday clinical practice is that it can be difficult to obtain the good two-dimensional TTE images that are essential for 3D evaluation. Three-dimensional acquisition and interpretation require more skill due to limitations of ultrasonography physics (i.e., acoustic shadowing, lateral resolution, far-field imaging, 3D volume rates). This difficulty may be more prominent among patients with tricuspid valve disease due to pacemaker leads and mechanical left-sided valves. The reported frequency of developing significant tricuspid regurgitation following pacemaker implantation varies, ranging from 7% to 45%, which requires thorough confirmation of free independent lead mobility that does not interfere with the native leaflet motion. Pacemaker lead positioning and impact of TV leaflet impingement can be difficult to determine by TTE and may require judicious transesophageal echocardiography (TEE) evaluation both with and without 3D evaluation. In addition, newly published data reveal that the conventional morphology of the tricuspid valve with three leaflets is only demonstrated in approximately half the cases, which could make it more difficult to determine pathology (e.g., leaflet impingement).

Since surgery of this valve is accompanied with increased mortality, it is essential to collect as many details as possible before referring to invasive treatment. At our institution, we have a multimodality approach, merging imaging (two-dimensional/3D TTE/TEE and cardiac computed tomography scan) and right heart catheterization data in the decision-making process for how best to treat patients with tricuspid valve disease.

Therefore, we fully support the encouragement that echocardiographers and sonographers should be proficient in the use of both 3D TTE and TEE.