Feasibility and diagnostic concordance of a transthoracic en face view for tricuspid valve morphological assessment
R Lopez Ditch, J J Acosta Castor, G Aire, X A Ortiz Leon, E L Posada-Martinez, J F Fritche Salazar, J A Arias-Godinez, M E Ruiz-Esparza, E Arias Sanchez, J R Cruz-Mendoza, P Sanchez Tapia, R T Hahn, H Rodriguez ZanellaAbstract
Background/Introduction
Moderate to severe tricuspid regurgitation is associated with adverse outcomes and increasing interest in transcatheter tricuspid valve interventions. Accurate anatomical characterisation of the tricuspid valve is essential for patient selection and procedural planning. Transesophageal echocardiography provides an en face view and represents the reference standard; however, its invasive nature limits widespread use. A modified transthoracic subcostal approach may allow non-invasive en face visualisation, although its diagnostic performance has not been systematically validated.
Purpose
To evaluate the feasibility, reproducibility, and diagnostic concordance of a transthoracic en face view of the tricuspid valve compared with transesophageal echocardiography.
Methods
In this observational cross-sectional study, consecutive adult patients referred for transesophageal echocardiography underwent prior two- and three-dimensional transthoracic echocardiography. An en face view of the tricuspid valve was obtained using a modified subcostal approach. Valve morphology was classified according to contemporary echocardiographic criteria. Feasibility was graded using a five-point scale. Diagnostic concordance and interobserver agreement were assessed using the kappa statistic.
Results
A total of 124 patients were included. Adequate en face visualisation was achieved in 71% of cases using two-dimensional transthoracic echocardiography. The most frequent morphological pattern was a three-leaflet configuration (72%), followed by a four-leaflet configuration with posterior leaflet segmentation (20%). Overall concordance between transthoracic and transesophageal echocardiography was substantial for both two- and three-dimensional imaging (kappa 0.68 and 0.69, respectively; p<0.005). In patients with good or fair image quality, concordance increased to almost perfect (kappa 0.82 and 0.84). Interobserver reproducibility was substantial (kappa 0.67).
Conclusion
A modified transthoracic subcostal en face view provides reliable and reproducible anatomical characterisation of the tricuspid valve. When image quality is adequate, this non-invasive approach shows high diagnostic concordance with transesophageal echocardiography and enables identification of anatomical variants. This technique may represent a valuable and widely accessible tool for routine assessment and preprocedural planning in patients undergoing transcatheter tricuspid valve interventions.Tricuspid valve morphology (Hahn).For image description, please refer to the figure legend and surrounding text.TTE–TEE concordance by image qualityFor image description, please refer to the figure legend and surrounding text.