• Hiroto Utsunomiya, Yuji Itabashi, Sayuki Kobayashi, Florian Rader, Robert J Siegel, and Takahiro Shiota.
• From the Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California.
• J Am Soc Echocardiogr. 2020 Feb 1; 33 (2): 191-200.e1.

BackgroundTricuspid annuloplasty for tricuspid regurgitation (TR) depends on the measurements of tricuspid annular diameter (TAD) obtained in an apical four-chamber view on two-dimensional (2D) transthoracic echocardiography (TTE). We performed a combined 2D and three-dimensional (3D) echocardiographic study to understand the impact of the size, shape, and orientation of a dilated annulus on the inconsistencies between measured 2D TTE-TAD and the actual annular diameter.MethodsA total of 185 patients with grade ≥3+ TR and 50 controls underwent 2D TTE and 3D transesophageal echocardiography (TEE) assessment of the tricuspid valve. The 3D TEE-TAD, defined as the longest dimension, and tricuspid annulus (TA) eccentricity index, defined as the shortest/longest dimension ratio, were obtained. The angle between the major tricuspid annulus axis and interatrial septum parallel to the vertical axis (α°) was measured as an index of TA orientation.ResultsCompared with controls, TR subgroups had a larger α° irrespective of TR etiology and cardiac rhythm (P < .05), with the posteriorly displaced TA most frequently noted in patients with atrial fibrillation. An excellent correlation was found between 3D TEE-TAD and 2D TTE-TAD, but 2D TTE-TAD was significantly smaller than 3D TEE-TAD (35.9 ± 5.4 vs 39.8 ± 5.7 mm; P < .001; bias, 3.9 ± 2.6 mm; limits of agreement, -1.1-8.9 mm). After multivariate adjustment, a larger 3D TEE-TAD and larger absolute value of 90° - α° were independent determinants of the bias between 3D TEE-TAD and 2D TTE-TAD (both P < .001).ConclusionsThe inconsistencies between measured 2D TTE-TAD and the actual annular diameter can be explained through morphologic factors such as TA size and orientation.Copyright © 2019 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.

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