echo

2.  Tricuspid valve leaflet displacement
 Morphology & Tethering of the TV leaflets
 Tricuspid valve motion and coaptation
 Dilatation of chambers
 TR assesment
 Dilation of the right atrioventricular junction (true
tricuspid annulus)
 Dilation of right ventricular outflow tract
 Exaggerated tricuspid anulus motion
 Left ventricular function and dimension.

3.  Tricuspid valve leaflet displacement
septal leaflet
 Normally --- apical displacement +
 Ebstein’s --- exaggerated displacement

4.  Ebsteins – 7 to 50mm,
 Normal tricuspid valve - 0 to 10 mm,
 Secundum atrial defect - 2 to 14 mm
 Severe TR- 2 to 15 mm
overlap with values for Ebstein ' s anomaly.
So, cut off is
15mm--- < 14yr
20mm--- >14 yr

5.  indexed to body surface area
 Ebstein 's anomaly --- 8.5 to 11.4 ,median 8.4mm/m2
 Normal --- 0 to 6.3, median 3.0mm/m2;
 ASD-- 0.9to 7.5, median 5.0mm/m2;
 TR --- 1.1 to 7.5, median 4.0mm/m2
CUT OFF IS --- 8 MM/M2

7.  Apical displacement of the septal leaflet from the
insertion of the anterior leaflet of the mitral valve by at
least 8 mm/m2

8. Morphology of leaflets
 Septal & posterior -
 Displacement
 Dysplasia
 Absence
 Anterior
 Elongation, redundancy , sail like appearance
 Distal attachments
 Mobility
 Fenestrations

9. Tethering of the tricuspid valve
 at least 3 accessory attachments of the leaflet to the
ventricular wall, causing restricted motion of the
leaflet.

10. Tethering

11.  Chamber enlargement
 Gose score

12. Ebstein’s: Echocardiographic
Severity index
 Celermajer et al
 grade (1 to 4)
 Gose score(Great
Ormond Street Score for
neonates)
Celermajer et al. Outcome in neonates with
Ebstein’s anomaly. JACC 1992; 19:1047-8.

13. GOSE score
Grade Ratio Mortality
1 <0.5 0%
2 0.5-0.99 8%
3
(acyanotic)
1-1.49 10% (neonatal)
45% (later)
3
(cyanotic)
1-1.49 100%
4 >1.5 100%

15. TR ASSESMENT
 spectral & colour
 direction, no, origin (fenestrations)

16. Tricuspid anulus
 Size – z score
comparison with mitral v annulus

17.  Occasionally = tissue bridge forms connecting leading
edges of septal and anterior lt turning the commissure
into a key hole --- TS
 Even imperforate TV if closes completely.

18. Sub valvular apparatus
 Short chordae may attach septal leaflet to ventricular
septum
 Sometimes chordae may absent with insertion of
leaflet directly to the ventricular septum.

19. RVOT
 RVOT OBS
 Aneurysmal dilation - equal to or greater than twice
the aortic root diameter (20%).

20.  interatrial communication - 80% to 94%
 Pda
 Bicuspid or atretic aortic valves.
 Pulmonary atresia or hypoplastic pulmonary
artery, PS
 Subaortic stenosis, COA
 MVP , accessory mitral valve tissue
 Muscle bands of LV ,double orifice MV.
 VSD
 LV non compaction

21. M mode
 Delayed closure of the tricuspid valve compared with
that of the mitral valve.
 delay in EA -- > 50 msec
 N --- 20-30 msec
 Paradoxical motion -IVS
 Increased RVdimension
 Increased excursion of AML of the mitral valve
 greater the delay in tricuspid valve closure, the more
severe the disease.

26. PLAX
 RV vol overload
 Paradoxical septal motion
 Free edges of TV seen in RV
 Displaced origins of leaflets
 Distinguish between anatomic & functional annulus
 Chordal attachments of ATL

27. PSAX
 Septal & ant leaflets seen, adherent to septal surface
 Length of ATL & its mobility
 Excessive size of ATL-systolic obstruction of RVOT
 Functional & anatomical pul atresia
 In neonates with severe ebsteins – pulmonary annulus
& branches are small

28. PSAX

29. A4C view
 Displacement index
 septal & ant leaflet
 Gose score
 BV function

30. A4C view

33. SUBCOSTAL VIEWS
 Coronal view- degree of adherence of septal leaflet to
ven myocardium & degree of elongation of ATL
 Superior angulation- RVOT – degree of encroachment
of ATL on RVOT.
 Sagittal view- sail like ATL & abnormal PTL
 ENFACE view - from coronal view, 30 - 45 degrees
clock wise rotation- all leaflets are seen.

34. CARPENTIER classification

35. dd
 Tricuspid dysplasia – nodular thicking and rolling
edges of leaflet with out displacement
 Ungaurded tricuspid valve – all 3 leaflets are absent

36. 3D ECHO
 Enables reconstruction of TV
 Visualise all 3 leaflets at same time – enface
view(surgical view)
 Better understanding of anotamy
 Degree of delamination
 Sub valvular apparatus

37. 3d ECHO

39. Pre op assesment
 Prognosis
 Tv repair vs replacement

40. Successful Monocusp Repair
 Freely mobile ATL
 Body of Leaflet and the Leading Edge can reach the
septum
 No Direct papillary muscle insertions
 Single Central Jet of TR
 No TV Chordal attachments in the RVOT
 Adequate Postop Functional RV size

42. Unfavorable Features for Monocusp Repair
 Tethered ATL with restricted mobility of Body of
Leaflet and the Leading Edge
 Direct papillary muscle insertions onto valve tissue
(no chordae)
 Multiple Jets of TR (fenestrations)
 TV Chordal attachments in the RVOT (near the PV)

44. Post op assesment
 Early post op –
 pericardial effusion, mediastinal hematoma,
 Intracardiac thrombus
 BV function, RWMA
 gr across TV,
 TR assesment( residual)
 Long term –
 RA, RV enlargement,
 TV fuction

47. SAS SCORE --- 0 TO 10
> 5 --- NO SURVIVORS
< 3 --- 91% SURVIVAL