Correlation of 2-Dimensional and 3-Dimensional Echocardiographic Analysis to Surgical Measurements of the Tricuspid Valve Annular Diameter


      This study sought to determine if 3-dimensional (3D) echocardiography would more closely correspond to direct surgical measurements of the maximal tricuspid valve (TV) annular diameter than 2-dimensional (2D) measurements.


      Prospective study.


      The cardiothoracic operating rooms (ORs) at Mount Sinai Medical Center in New York, NY.


      Fifty-nine patients over 18 years of age underwent elective mitral valve surgery for severe mitral regurgitation from 2014 to 2015.



      Measurements and Main Results

      Two-dimensional and 3D data sets and surgical TV annular dimensions were measured. Bland-Altman analysis was conducted and absolute differences were compared using paired t tests and the McNemar test.
      The observed mean difference between the 2D measurements by transgastric right ventricular diastolic view and the surgical measurements was 0.21 cm (standard deviation [SD] = 0.36 cm); the mean difference between the 3D measurements and surgical measures was -0.03 cm (SD = 0.19 cm). The McNemar test showed that the rate of highly successful measurements, defined as those within 0.2 cm of the true surgical score, using the 3D technique (66%) was significantly better than the rate of highly successful measurements using the 2D technique (25%), p< 0.01, 2-sided.


      Three-dimensional imaging and measurement of the TV annular diameter is feasible in the OR setting. The superiority of the 3D measurements versus 2D measurements allows for greater precision and accuracy and may guide better intraoperative surgical decision-making.

      Key Words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Cardiothoracic and Vascular Anesthesia
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Di Mauro M
        • Bezante GP
        • Di Baldassarre A
        • et al.
        Functional tricuspid regurgitation: An underestimated issue.
        Int J Cardiol. 2013; 168: 707-715
        • Matsunaga A
        • Duran CMG
        Progression of tricuspid regurgitation after repaired functional ischemic mitral regurgitation.
        Circulation. 2005; 112: I453-I457
        • Fischer GW
        Atrial fibrillation in the elderly.
        Anesthesiol Clin. 2009; 27: 417-427
        • Lancellotti P
        • Moura L
        • Pierard LA
        • et al.
        European Association of Echocardiography recommendations for the assessment of valvular regurgitation. Part 2: Mitral and tricuspid regurgitation (native valve disease).
        Eur J Echocardiogr. 2010; 11: 307-332
        • Sorajja P
        • Bozkurt B
        • DeMets D
        • et al.
        2014 AHA/ACC guideline for the management of patients with valvular heart disease.
        J Thorac Cardiovasc Surg. 2014; 148: e1
        • Vahanian A
        • Alfieri O
        • Andreotti F
        Guidelines on the management of valvular heart disease (version 2012): The Joint Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS).
        Eur J Cardiothorac Surg. 2012; 42: S1
        • Carpentier A
        Cardiac valve surgery–the "French correction".
        J Thorac Cardiovasc Surg. 1983; 86: 323-337
        • Maslow AD
        • Schwartz C
        • Singh AK
        Assessment of the tricuspid valve: A comparison of four transesophageal echocardiographic windows.
        J Cardiothorac Vasc Anesth. 2005; 18: 719-724
        • Tsang W
        • Lang RM
        Three-dimensional echocardiography is essential for intraoperative assessment of mitral regurgitation.
        Circulation. 2013; 128: 643-652
        • Ben MD SBZ
        • Ben Zekry S
        • MD SFN
        • et al.
        Comparative accuracy of two- and three-dimensional transthoracic and transesophageal echocardiography in identifying mitral valve pathology in patients undergoing mitral valve repair: Initial observations.
        J Am Soc Echocardiogr. 2011; 24: 1079-1085
        • Tsang W
        • Freed BH
        • Lang RM
        The role of 3-dimensional echocardiography in the diagnosis and management of mitral valve disease: Myxomatous valve disease.
        Cardiol Clin. 2013; 31: 203-215
        • Badano LP
        • Agricola E
        • de Isla LP
        • et al.
        Evaluation of the tricuspid valve morphology and function by transthoracic real-time three-dimensional echocardiography.
        Eur J Echocardiogr. 2009; 10: 477-484
        • Anwar AM
        • Soliman OII
        • Nemes A
        • et al.
        Value of assessment of tricuspid annulus: Real-time three-dimensional echocardiography and magnetic resonance imaging.
        Int J Cardiovasc Imaging. 2007; 23: 701-705
        • Schnabel R
        • Khaw AV
        • Bardeleben von RS
        • et al.
        Assessment of the tricuspid valve morphology by transthoracic real-time-3D-echocardiography.
        Echocardiography. 2005; 22: 15-23
        • Anwar AM
        • Geleijnse ML
        • Soliman OII
        • et al.
        Assessment of normal tricuspid valve anatomy in adults by real-time three-dimensional echocardiography.
        Int J Cardiovasc Imaging. 2007; 23: 717-724
        • Anwar AM
        • Geleijnse ML
        • Cate Ten FJ
        • et al.
        Assessment of tricuspid valve annulus size, shape and function using real-time three-dimensional echocardiography.
        Interact Cardiovasc Thorac Surg. 2006; 5: 683-687
        • Ton-Nu T-T
        • Yosefy C
        • Fan D
        • et al.
        Geometric determinants of functional tricuspid regurgitation.
        Circulation. 2006; 114: 143-149
        • Kwan J
        • Kim G-C
        • Jeon M-J
        • et al.
        3D geometry of a normal tricuspid annulus during systole: A comparison study with the mitral annulus using real-time 3D echocardiography.
        Eur J Echocardiogr. 2006; 8: 375-383
        • Fukuda S
        • Saracino G
        • Matsumura Y
        Three-dimensional geometry of the tricuspid annulus in healthy subjects and in patients with functional tricuspid regurgitation: A real-time, 3-dimensional echocardiographic study.
        Circulation. 2006; 114: I492-I498
        • Dreyfus GD
        • Chan KMJ
        Functional tricuspid regurgitation: A more complex entity than it appears.
        Heart. 2009; 95: 868-869
        • Park Y-H
        • Song J-M
        • Lee E-Y
        • et al.
        Geometric and hemodynamic determinants of functional tricuspid regurgitation: A real-time three-dimensional echocardiography study.
        Int J Cardiol. 2007; 124: 160-165
        • Lang RM
        • Lang RM
        • Tsang W
        • et al.
        Valvular heart disease.
        J Am Coll Cardiol. 2011; 58: 1933-1944
        • Ring L
        • Rana BS
        • Kydd A
        • et al.
        Dynamics of the tricuspid valve annulus in normal and dilated right hearts: A three-dimensional transoesophageal echocardiography study.
        Eur Heart J Cardiovasc Imaging. 2012; 13: 756-762
        • Dreyfus GD
        • Corbi PJ
        • Chan KM
        • Bahrami T
        Secondary tricuspid regurgitation or dilatation: which should be the criteria for surgical repair?.
        Ann Thorac Surg. 2005; 79: 127-132
        • Owais K
        • Taylor CE
        • Jiang L
        • et al.
        Tricuspid annulus: A three-dimensional deconstruction and reconstruction.
        Ann Thorac Surg. 2014; 98: 1536-1542
        • Knio ZO
        • Montealegre-Gallegos M
        • Yeh L
        • et al.
        Tricuspid annulus: A spatial and temporal analysis.
        Ann Card Anaesth. 2016; 19: 599-605
        • Montealegre-Gallegos M
        • Bergman R
        • Jiang L
        • et al.
        Tricuspid valve: An intraoperative echocardiographic perspective.
        J Cardiothorac Vasc Anesth. 2014; 28: 761
        • Hai T
        • Amador Y
        • Mahmood F
        • et al.
        Changes in tricuspid annular geometry in patients with functional tricuspid regurgitation.
        J Cardiothorac Vasc Anesth. 2017; 31: 2106
        • Dreyfus J
        • Durand-Viel G
        • Raffoul R
        • et al.
        Comparison of 2-dimensional, 3-dimensional, and surgical measurements of the tricuspid annulus size: Clinical Perspective.
        Circulation: Cardiovascular Imaging. 2015; 8e003241
        • Mahmood F
        • Kim H
        • Chaudary B
        • et al.
        Tricuspid annular geometry: A three-dimensional transesophageal echocardiographic study.
        J Cardiothorac Vasc Anesth. 2013; 27: 639-646
        • Van de Veire NR
        • Braun J
        • Delgado V
        • et al.
        Tricuspid annuloplasty prevents right ventricular dilatation and progression of tricuspid regurgitation in patients with tricuspid annular dilatation undergoing mitral valve repair.
        J Thorac Cardiovasc Surg. 2010; 141: 1431-1439
        • Sagie A
        • Schwammenthal E
        • Padial LR
        Determinants of functional tricuspid regurgitation in incomplete tricuspid valve closure: Doppler color flow study of 109 patients.
        Journal Am Coll Cardiol. 1994; 24: 446-453
        • Shiran A
        • Sagie A
        Tricuspid regurgitation in mitral valve disease incidence, prognostic implications, mechanism, and management.
        J Am Coll Cardiol. 2009; 53: 401-408
        • Chikwe J
        • Itagaki S
        • Anyanwu A
        • et al.
        Impact of concomitant tricuspid annuloplasty on tricuspid regurgitation, right ventricular function, and pulmonary artery hypertension after repair of mitral valve prolapse.
        J Am Coll Cardiol. 2015; 65: 1931-1938
        • Benedetto U
        • Melina G
        • Angeloni E
        • et al.
        Prophylactic tricuspid annuloplasty in patients with dilated tricuspid annulus undergoing mitral valve surgery.
        J Thorac Cardiovasc Surg. 2012; 143: 632-638

      Linked Article

      • Intraoperative Measurement of the Tricuspid Annulus: To 3D or not to 3D?
        Journal of Cardiothoracic and Vascular AnesthesiaVol. 33Issue 1
        • Preview
          TIME REMAINS a precious commodity for the cardiac anesthesiologist when performing a comprehensive echocardiography examination, and the question of whether to perform yet another 3-dimensional (3D) assessment technique in this regard is not new. In 2007, Culp et al. set out to validate cardiac output measurements by using a standard multiplanar probe and now obsolete 3D software.1 Although there was good correlation with thermodilution (correlation coefficient 0.86), an analysis time of 7 minutes made this technique impractical for cases involving unstable cardiac patients.
        • Full-Text
        • PDF