Three-dimensional echocardiography to asses the mechanism of tricuspid valve bioprosthesis dysfunction

by Hugo Rodríguez-Zanella, MD; Jose Antonio Arias MD, Luigi Badano, MD, PhD
National institute of cardiology of Mexico, “Ignacio Chávez”. Department of cardiac, thoracic and vascular sciences, University of Padua, School of Medicine, Padua, Italy

Clinical Case

  • Female 67 years old
  • History of Rheumatic Heart Disease
  • Mitral Mechanical Prosthetic Valve
  • Tricuspid Biological Prosthetic Valve
  • Presented with a 3 weeks history of progressive dyspnea, leg edema

Two-dimensional echocardiography from apical four chamber view. The prosthetic tricuspid valve is not well visualized due to poor acustic window.

Color doppler shows severe intraprosthetic regurgitation and flow acceleration through the valve.

Spectral CW Doppler across the tricuspid valve, showing increased gradients and a dense holosystolic jet of tricuspid regurgitation (TR).

Three-dimensional echocardiography. Volume rendered Zoom 3D. En face view of the tricuspid prosthetic valve from the atrial perspective. Note the presence of a mobile structure protruding through the valve.

Mobile structure (red arrow) compatible with thrombus protruding through the valve.

Three-dimensional color doppler Zoom 3D of the tricuspid prosthesis from the atrial perspective. Note the presence of a central TR jet.

Systolic frame of the same dataset, showing the central position of severe TR.

Multislice display of the transthoracic 3D data set of the bioprosthetic valve was used to obtain anatomical oriented planes. Note the presence of thrombus interfering with proper leaflet coaptation.

Still frame showing the presence of thrombus in the center of the valve (red arrow), responsible for the severe TR.

Key messages

2D/Doppler echocardiography enabled:

  • Diagnosis of prosthetic valve dysfunction;
  • Identification of severe tricuspid regurgitation.

3D echocardiography allowed:

  • Detailed anatomic evaluation of the biological prosthetic valve in real time;
  • Accurate identification of the mechanism of prosthetic valve dysfunction important for appropriate treatment selection;
  • Anatomically sound measurement of thrombus size.


  1. Lancellotti P, Pibarot P, Chambers J, Edvardsen T, Delgado V, Dulgheru R, et al. Recommendations for the imaging assessment of prosthetic heart valves: a report from the European Association of Cardiovascular Imaging endorsed by the Chinese Society of Echocardiography, the Inter-American Society of Echocardiography, and the Brazilian. Eur Hear J – Cardiovasc Imaging 2016;17(6):589–90.
  2. Egbe AC, Pislaru S V., Pellikka PA, Poterucha JT, Schaff H V., Maleszewski JJ, et al. Bioprosthetic Valve Thrombosis Versus Structural Failure: Clinical and Echocardiographic Predictors. J Am Coll Cardiol. 2015;66(21):2285–94.

Hugo Rodríguez Zanella MD

Dr. Rodríguez Zanella is a Cardiologist and Staff member of the National Institute of Cardiology of Mexico, “Ignacio Chávez”. He completed medical school, Cardiology and Echocardiography Fellowship at the National University of Mexico (UNAM) and the National Institute of Cardiology of Mexico, “Ignacio Chávez” in Mexico City. He is currently a training and research fellow in advanced echocardiography at the University of Padua, Italy.