Isolated Tricuspid Valve Prolapse Diagnosed by Echocardiography

DARREN JACKSON HARRY R. GIBBS, M.D. CHI-SUNG ZEE-CHENG, M.D.

Kansas Cify, Missouri

From the Division of Cardiology, Department of Medicine, University of Missouri-Kansas City, School of Medicine, Kansas City, Missouri. Re- quests for reprints should be addressed to Dr. Chi-Sung Zee-Cheng, University of Missouri- Kansas City, School of Medicine, 2411 Holmes, Kansas City, Missouri 64108. Manuscript ac- cepted October 24, 1984.

Isolated tricuspid valve prolapse in the absence of mitral valve prolapse or other cardiac defects has not been previously noted. This report describes a patient who on both M-mode and two-dimensional echo- cardiography demonstrated tricuspid prolapse without other associat- ed abnormalities. The implications of this finding are discussed.

Tricuspid valve prolapse in association with mitral valve prolapse has been well described [i-5]. Isolated tricuspid valve prolapse has rarely been repotted [6]. However, these previously described cases of isolated tricuspid valve prolapse have been seen in association with rheumatic valvular heart disease, pulmonary hypertension with right ventricular failure, and other structural abnormalities, such as atrial septal defect. Other cases of isolated tricuspid valve prolapse have been poorly docu- mented. A case of isolated tricuspid valve prolapse documented by both M-mode and two-dimensional echocardiography is described.

CASE REPORT

An 84-year-old black man without significant past cardiac history was being evaluated for asymptomatic ventricular ectopy noted on a continuous ambulatory monitor. On examination, his blood pressure was 144/80 mm Hg; the heart rate was 60 beats per minute. He was a normal-appearing elderly black man without stigmata of Marfan’s syndrome. His lungs were clear bilaterally. A grade I/VI systolic ejection murmur was noted at the left sternal border without radiation. A mid-systolic click was heard. A late systolic murmur was not appreciated. There was normal physiologic split- ting of the second heart sound without accentuation of the pulmonic component. Electrocardiography revealed occasional ventricular ectopy but otherwise unremarkable findings. Chest radiography revealed a normal cardiac silhouette. Both M-mode and two-dimensional echocardiography were performed using a Varian phase-arrayed sector scanner. The M-mode study was performed from the left parasternal acoustic window. The tricus- pid valve was well visualized and consistently showed evidence of posteri- or motion, predominantly during mid-to-late systole, consistent with the diagnosis of tricuspid valve prolapse (Figure IA). The mitral valve, how- ever, was normal and exhibited no evidence of posterior motion of the leaflets during systole (Figure 1B). On the two-dimensional study, the tricuspid valve was technically difficult to visualize in the apical four- chamber view. However, in the parasternal short-axis view, it was well visualized during both diastole (Figure 2A) and systole (Figure 2B), and demonstrated prolapse of the tricuspid valve leaflets beyond the tricuspid valve annulus during systole. The mitral valve in the apical four-chamber view was well visualized both in diastole (Figure 2C) and in systole (Figure 2D). It demonstrated no evidence of prolapse. No other structural abnor- malities were noted on either the M-mode or the two-dimensional echocar- diographic study.

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Figure 1. M-mode echocardiogram at the level of the tricuspid valve (A), showing the systolic posterior motion (arrow) consistent with tricuspid valve prolapse, andat the level of the mitral valve (B), showing the absence of mitral valve prolapse. IVS = interventricular septum: L V = left ventricle; MV = mitral valve; RV = right ventricle; TV = tricuspid valve.

COMMENTS

Tricuspid valve prolapse has been characterized by both invasive and noninvasive methods. Ainsworth and asso- ciates [7] have reported cineangiographic features of tricuspid valve prolapse. In fact, angiographically demon- strated isolated tricuspid valve prolapse has been report- ed with an incidence of as high as 15 percent. However, similar to the situation with the mitral valve, criteria for angiographic diagnosis of tricuspid valve prolapse have not been standardized. The reason for the lack of stan- dardization is due to technical difficulties in obtaining adequate visualization of the tricuspid valve. The tip of the catheter must be placed in the inflow track of the right ventricle; optimal placement is mandatory to minimize arrhythmias and to demonstrate adequately the ventricular surface of the tricuspid valve. Several ventriculograms may be required before the valve motion and anatomy are unequivocally visualized. Prolapse of the tricuspid valve has also been assessed echocardiographically. The pat- tern of tricuspid valve prolapse on M-mode echocardio- graphy is similar to that described for mitral valve prolapse [1,2]. This consists of either midto-late or pansystolic posterior motion of the tricuspid valve. However, M-mode echocardiographic visualization of the tricuspid valve is much more difficult than that of the mitral valve. The anterior and the posterior tricuspid leaflets can usually be seen only in patients with dilated right .ventricles. The septal leaflet is rarely seen on M-mode echocardio-

graphy. In addition, M-mode echocardiographic imaging of the tricuspid valve has been inconsistent. Superior visualization of the tricuspid valve has been available with ‘two-dimensional echocardiography [3-51. All three tri- cuspid valve leaflets can be visualized by this method using both the long- and the short-axis view of the right ventricular inflow tract from the left parastemal area, apical four-chamber view, and the subxyphoid view [6]. In normal subjects, the right ventricle and.the right atrium are clearly separated in systole by the tricuspid valve annulus. The leaflets do not cross the atrioventricular ring at any time. On the contrary, in patients with tricuspid valve prolapse, the leaflets are seen to bulge into the right atrium, crossing the atrioventricular ring.

Isolated tricuspid valve prolapse has rarely been de- scribed. However, these reported cases have been seen in association with rheumatic valvular heart disease, pul- monary hypertension with right ventricular failure, and other structural abnormalities, such as atrial septal defect. It has also been seen following a right ventricular wound, with tricuspid valve vegetation, with a large pericardial effusion, and in a patient with mitral regurgitation due to apparent chordal rupture. In a very large study using predominantly M-mode echocardiography in 562 pa- tients, Werner et al [2] assessed the tricuspid valve in 500 consecutive patients without mitral valve prolapse or con- genital heart disease. No patient was found to have an echocardiographic pattern of tricuspid valve prolapse. Morganroth et al [5], employing two-dimensional echo-

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Figure 2. Two-dimensional echocar- diograms and schematic diagrams of the parasternal short-axis view showing the tricuspid valve in diastole (A) and the prolapse that occurs in systole (B). Two- dimensional echocardiograms and sche- matic diagrams of the apical four-cham ber view showing the mitral valve in di- astole (c) and the absence of prolapse in systole (0). LV = left ventricle; MV = mitral valve; RV = right ventricle; TV = tricuspid valve.

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cardiography, were also unable to demonstrate a single case of isolated tricuspid valve prolapse. The patient described in this report vividly demonstrated tricuspid valve prolapse in the absence of mitral valve prolapse or other structural abnormalities. This finding is significant because it suggests that in those patients with a mid- systolic click and a normal mitral valve, the tricuspid valve needs to be thoroughly evaluated as well. In addition, the

question of prophylaxis against infective endocarditis in patients with isolated tricuspid valve prolapse is raised.

ACKNOWLEDGMENT

We are grateful for the helpful comments and suggestions of Dr. Barbara Nohinek, and the assistance of Jackie Hall in the preparation of the manuscript.

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REFERENCES

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2. Werner JA, Schiller NB, Prasquier R: Occurrence and signifi- cance of echocardiographically demonstrated tricuspid valve prolapse. Am Heart J 1978; 96: 180-186.

3. Sobolski J, Ledune J, Vandermoten P, Berkenboom G, Stou- pel E, Deare S: Tricuspid valve prolapse: two dimensional echocardiographic aspects. Acta Cardiol 1980; 35: 461-467.

4. Mardelli TJ, Morganroth J, Chen CC, Naito M, Verge1 J: Tricus- pid valve prolapse diagnosed by cross-sectional echocar-

diography. Chest 1981; 79: 201-205. 5. Morganroth J, Jones RH, Chen CC, Naito M: Two dimensional

echocardiography in mitral, aortic and tricuspid valve pro- lapse: the clinical problem, cardiac nuclear imaging con- siderations and a proposed standard for diagnosis. Am J Cardiol 1980; 46: 1164-l 177.

6. Brown AK, Anderson V: Two dimensional echocardiography and the tricuspid valve: leaflet definition and prolapse. Br Heart J 1983; 49: 495-500.

7. Ainsworth RP, Hartmann AF, Aker U, Schad N: Tricuspid valve prolapse with late systolic tricuspid insufficiency. Radiology 1973; 107: 309-3 11.

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