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| Tricuspid Valve Leaflets |
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| The tricuspid valve leaflets should be inspected for mobility, thickness, calcifications, fibrosis, and coaptation. The degree of leaflet separation at the coaptation point and the location of the coaptation point should be noted. Three leaflets with thin valves should be visualized in the various TEE views. The valve leaflets are freely mobile and fully open to the adjacent myocardial wall. The chordae are thin and are usually barely visible. The papillary muscles may be visible but usually are only partially visible. Thickening, restriction, flail, prolapse and calcification are all abnormal findings indicating underlying pathology. |
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| Tricuspid Annulus |
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| The annulus is assessed for size, location and motion. The normal tricuspid valve annulus diameter is 28 � 5 mm.
Tricuspid annular dilation is usually secondary to other disease processes (pulmonary hypertension, left sided disease).
The normal annulus location is less than 10mm lower (apically displaced) than the mitral annulus. The annulus also has an apical motion during systole. |
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| Right Atrium |
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| The right atrium should be assessed for size and function . Spontaneous echo contrast in the atrium is not normal and indicates low flow states or tricuspid stenosis. Visualization of the RAA should be included to look for thrombus and/or a lack of normal atrial appendage contraction (indicating atrial fibrillation). The motion of the interatrial septum can indicate the relative pressure of the right and left atrium. |
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| Right Atrial Size |
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Right atrial size can be measured by diameters, areas, or volume calculations. Right atrial size is difficult to measure in 2D since there is no clear A-P or superior-inferior axis. This makes is more difficult to measure RA size and volumes compared to the LA. Midesophageal 4 chamber is a view to determine antero-posterior dimensions and medial-lateral dimension .
Normal A-P diameter is 38 mm and M-L dimension is 38 mm. The diameter measurement should be taken at end-systole. |
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| Right Atrial Enlargement (RAE) |
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| Increased right atrial size is caused by increased right atrial pressure. Increased right atrial pressure is due to volume overload or pressure overload. Volume overload of the right ventricle due to tricuspid regurgitation, right ventricular failure, or an ASD and causes right atrial enlargement. Pressure overload of the right ventricle is due to pulmonary stenosis or pulmonary hypertension. Right atrial pressure overload is due to tricuspid stenosis. Pressure overload at the atrial or ventricular level can cause increased right atrial pressure. |
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| Measurement |
Dimension |
| RA Diameter (medial-lateral) |
< 4.6 cm |
| RA Diameter (superior-inferior) |
< 4.9 cm |
| RA Volume |
< 33 m/m2 |
| RVID (medial-lateral) |
< 4.3 cm |
| RVEDA |
< 35.5 cm2 |
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Table 10.2.1 |
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| Right Ventricle |
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| The right ventricle should be assessed for size and function. Normal RV size is < 4.3 cm in diameter and end diastolic area is < 35.5 cm2. Thickness of the right ventricular free wall and function of the right ventricle should be assessed. The free wall is normally 0.7 cm thick and thickens and exhibits movement towards the center of the right ventricular cavity during systole. The right ventricular apex is normally proximal to the left ventricular apex. If the right ventricular apex is equal to or distal to the left ventricular apex then the right ventricle is dilated or dextrocardia is present. |
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