ECG: The ECG often provides clues to the possible cause of TI:
- z. e.g. Q- wave in the inferior leads as an indication of a posterior wall infarction).
- Sokolow- Lyon index ( RV1 +SV5/6 > 1.05 mV) (Bob 2001)
- high, slender R in V1, right deviation of the cardiac axis
- pre-excitations (can be found in patients with Ebstein anomaly)
- if sinus rhythm is present, evidence of enlarged right atrium may be found (e.g., P- dextroatrial, P in II and III is peak positive with > 0.2 mV and in V1 , V2 the positive portion of the P- spike is peak positive and higher than 0.15 mV)
- Atrial fibrillation (Kasper 2015)
- (in)complete right bundle branch block (Pinger 2019).
Echocardiography: Echocardiography is usually diagnostic.
A systolic pressure in the right ventricle:
- < 40 mmHg indicates primary TI in valve deformity.
- > 55 mmHg indicates secondary TI (Pinger 2019).
Otherwise, echocardiographic imaging can be performed:
On one- and two-dimensional echo:
Dilatation of the right ventricle
Dilatation of the right atrium
the superior and inferior vena cava are dilated (>1 cm/m 2)
during inspiration the systolic collapse of the inferior vena cava is abolished (Gerok 2007)
In CW- Doppler, systolic PAP can be estimated (Kasper 2015).
In contrast echo:
when the tricuspid valve is plumbed, a return flow of contrast medium from the right ventricle into the right atrium is detectable
when injected into the cubital vein, systolic reflux into the inferior vena cava and hepatic veins is found (Gerok 2007)
In Doppler echocardiography:
In color Doppler echocardiography:
The regurgitation volume detected by color Doppler is often increased in routine examinations. Evidence of mild TI is found in approximately 70% of normal subjects (Pinger 2019). (Kasper 2015). Color Doppler can also be used to determine the severity of TI (Kasper 2015).
Quantification of TI according to EAE 2010 / 2013:
- I. mild TI:
- Morphology of the valve normal or abnormal.
- V. contracta (mm) not defined
- PISA radius (mm)x1 ≤ 5
- EROA (mm 2) not defined
- R vol (ml) not defined
- PW- signal of inflow normal
- CW- signal of TI weak/ parabolic
- Hepatic venous flow systolic dominated
- II. moderate TI
- Valve morphology normal or abnormal
- V. contracta (mm) < 7
- PISA radius (mm)x1 6 - 9
- EROA (mm 2) not defined
- R Vol (ml) not defined
- PW- Signal of inflow normal
- CW- signal of TI dense/ parabolic
- Hepatic venous flow systolic attenuated
- III. severe TI
- Morphology of the valve abnormal
- V. contracta (mm) > 7
- PISA radius (mm)x1 > 9
- EROA (mm 2) ≥ 40
- R vol (ml) ≥ 45
- PW- signal of inflow E- waves dominated > 1 m/s.
- CW- signal of TI dense, triangular with early peak (peak < 2m/s possible).
- Hepatic venous flow systolic flow reversal (Pinger 2019).
A V. contracta > 6.5 mm indicates severe TI with a specificity of 93% (Pinger 2019).
The use of jet area-as described in sometimes in the literature-is not recommended for quantification according to EAE (Pinger 2019).
Another classification is the classification according to Carpentier and Brizard (2006), which is based AN the mobility and morphology of the valve leaflets.
- Type I: There is annulus dilatation or valve perforation with normal leaflet mobility.
- Type II: Excessive mobility of the leaflets due to prolapse.
- Type III: In type III, there is restrictive leaflet mobility resulting from valvulopathy or functional TI (Pinger 2019)
X-ray thorax: The x-ray shows the enlarged right ventricle and the also enlarged right atrium. The posterior-anterior ray path shows a triangular configuration of the heart with protrusion of the enhanced right border of the heart. In the lateral pathway, the outflow tract of the right ventricle bulges into the retrosternal space.
In primary TI, there is also:
- a relative insufficiency of blood flow to the lungs.
In secondary TI, there may be:
- signs of pulmonary hyperemia
- signs of hypertension
The mediastinum is usually widened (by the superior vena cava and the azygos vein). There may be a cranial displacement of the diaphragm (caused by ascites) (Erdmann 2006).
Cardiac MRI: In echocardiography sometimes cannot be accurately determined:
- severity of TI
- pulmoarterial pressure
- size and systolic function of the right ventricle.
If there are problems with this and a 3-D echocardiogram is not available, it is recommended that a cardiac MRI be performed (Kasper 2015).
Right heart catheterization: The following changes may occur with right heart catheterization:
- the mean pressure in the right atrium is elevated (RAP)
- there is an accentuation of the v- wave.
During inspiration these hemodynamic changes are intensified (so-called positive Kußmaul sign [Erdmann 2006])
- the Y-valley is intensified
- in severe TI, the contour of the right atrial pressure curve is very similar to the right ventricular pressure curve, but shows a lower amplitude (so-called ventriculized RA curve)
- Right ventricular end-diastolic pressure (RVEDP) is elevated (Pinger 2019).
Dextrocardiography: Angiographic quantification of a TI using dextrocardiography:
With dextrocardiography, it is possible to angiographically visualize TI as systolic contrast reflux into the right atrium. However, because regurgitation can also be induced by catheter position or by triggering extrasystoles during contrast administration, the diagnostic value of dextrocardiography is often doubted for this reason. Ideally, the shaft of the angiographic catheter should lie exactly in the middle of the ostium of the tricuspid valve, as this can prevent the valve from being artificially held open (Lapp 2014).
According to ACC / AHA 2014, there is a IIa- indication for catheter-based evaluation if only an inadequate assessment was possible by noninvasive diagnostics (Pinger 2019).
Angiographic quantification:
- Grade I: Only minimal regurgitation of the contrast medium into the right atrium is detectable
- Grade II: Only partial contrast of the right atrium is found; however, this remains during diastole
- Grade III: Complete and dense contrast of the entire right atrium.
- Grade IV: At this stage, there is contrast reflux in the hepatic veins and complete and immediate contrast of the right atrium, which additionally increases with each cardiac beat (Pinger 2019)