Tricuspid regurgitation cardiac CT
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Basir Gill, M.B.B.S, M.D.[2]
Overview
While echocardiography serves as the baseline for diagnosing tricuspid regurgitation (TR), cardiac computed tomography (CT) has become a mandatory adjunct for detailed anatomical mapping and planning transcatheter interventions.[1][2] Its primary advantage lies in its high spatial resolution and 3D imaging capabilities, which provide clarity in patients where poor acoustic windows limit the utility of ultrasound.[1][2]
Anatomical Assessment and TR Morphology
- Leaflet Configuration: CT is used to identify specific leaflet variations (Types I–IV), which is a vital step in understanding the underlying mechanism of the regurgitation.[3]
- Annular Measurement: CT is considered the gold standard for calculating the 3D dimensions of the tricuspid annulus, including its perimeter, area, and specific diameters.[2][4]
- Right-Sided Remodeling: By providing precise measurements of right ventricular (RV) volume and right atrial (RA) size, CT helps clinicians distinguish between "atrial secondary TR" (driven by atrial enlargement) and "ventricular secondary TR" (driven by RV remodeling).[5][2]
Pre-procedural planning for Transcatheter Interventions
For patients being considered for transcatheter tricuspid valve replacement (TTVR) or repair, cardiac CT is a prerequisite for procedural success:[2][6]
- Peripheral and Central Access: CT scans are used to check the caliber and path of the iliac and femoral veins, as well as the alignment of the inferior vena cava (IVC), to plan the device delivery route.[2]
- Right Coronary Artery (RCA) Mapping: Because the RCA runs in close proximity to the tricuspid annulus, CT is used to visualize its course to prevent accidental compression or injury during annuloplasty or valve replacement.[2]
- Evaluation of CIED Leads: In patients with existing pacemakers or defibrillators, CT determines if a lead is a "bystander" or if it is physically impinging on a leaflet, which helps predict the risk of lead entrapment during the procedure.[7][6]
- Optimizing Fluoroscopy: CT modeling allows the heart team to pre-calculate the best "coplanar" angles for fluoroscopy, ensuring optimal visualization of the annular plane during the operation.[2]
Quantitative Assessment of TR Severity
CT is increasingly used to support the grading of TR when other imaging results are ambiguous:
- Anatomic Regurgitant Orifice Area (AROA): High-definition CT can measure the physical systolic gap between leaflets, providing an AROA value that correlates with the severity of the leak.[2]
- Venous Contrast Reflux: The observation of contrast dye flowing backward into the hepatic veins and IVC during a scan serves as a strong qualitative indicator of advanced TR.[2]
Technical Considerations
- Contrast Protocols: To avoid artifacts in the right atrium that could mask the thin valve leaflets, specialized "split-bolus" or "chaser" contrast injection methods are required.[2]
- ECG Gating: The scan must be synced with an ECG to allow for multi-phase visualization, ensuring the valve is captured during mid-systole when the regurgitant volume is typically at its peak.[2]
| Feature | Echocardiography (TTE/TEE) | Cardiac CT |
|---|---|---|
| Primary Strength | Real-time hemodynamics and flow | Superior spatial resolution and anatomy |
| Annular Sizing | Less precise due to 2D/3D limitations | Preferred standard for 3D measurements |
| RCA Proximity | Often difficult to visualize | Excellent for mapping coronary paths |
| Limitations | Dependent on acoustic windows | Involves radiation and contrast agents |
References
- ↑ 1.0 1.1 Praz, F., Borger, M. A., Lanz, J., Marin-Cuartas, M., Abreu, A., Adamo, M., Ajmone Marsan, N., Barili, F., Bonaros, N., Cosyns, B., De Paulis, R., Gamra, H., Jahangiri, M., Jeppsson, A., Klautz, R. J. M., Mores, B., Pérez-David, E., Pöss, J., Prendergast, B. D., … Moorjani, N. (2025). 2025 ESC/EACTS Guidelines for the management of valvular heart disease: Developed by the task force for the management of valvular heart disease of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS). European Heart Journal, 46(44), 4635–4736. https://doi.org/10.1093/eurheartj/ehaf194
- ↑ 2.00 2.01 2.02 2.03 2.04 2.05 2.06 2.07 2.08 2.09 2.10 2.11 Hahn, R. T., Saric, M., Faletra, F. F., Garg, R., Gillam, L. D., Horton, K., Khalique, O. K., Little, S. H., Mackensen, G. B., Oh, J., Quader, N., Safi, L., Scalia, G. M., & Lang, R. M. (2022). Recommended standards for the performance of transesophageal echocardiographic screening for structural heart intervention: From the American society of echocardiography. Journal of the American Society of Echocardiography: Official Publication of the American Society of Echocardiography, 35(1), 1–76. https://doi.org/10.1016/j.echo.2021.07.006
- ↑ Hahn, R. T., Weckbach, L. T., Noack, T., Hamid, N., Kitamura, M., Bae, R., Lurz, P., Kodali, S. K., Sorajja, P., Hausleiter, J., & Nabauer, M. (2021). Proposal for a standard echocardiographic tricuspid valve nomenclature. JACC. Cardiovascular Imaging, 14(7), 1299–1305. https://doi.org/10.1016/j.jcmg.2021.01.012
- ↑ Schulz-Menger, J., Bluemke, D. A., Bremerich, J., Flamm, S. D., Fogel, M. A., Friedrich, M. G., Kim, R. J., von Knobelsdorff-Brenkenhoff, F., Kramer, C. M., Pennell, D. J., Plein, S., & Nagel, E. (2020). Standardized image interpretation and post-processing in cardiovascular magnetic resonance - 2020 update : Society for Cardiovascular Magnetic Resonance (SCMR): Board of Trustees Task Force on Standardized Post-Processing: Society for Cardiovascular Magnetic Resonance (SCMR): Board of Trustees Task Force on Standardized Post-Processing. Journal of Cardiovascular Magnetic Resonance: Official Journal of the Society for Cardiovascular Magnetic Resonance, 22(1), 19. https://doi.org/10.1186/s12968-020-00610-6
- ↑ Hahn, R. T., Lawlor MD MS, M., Davidson, C. J., Badhwar, V., Sannino, A., Spitzer, E., Lurz, P., Lindman MD MSCI, B., Topilsky, Y., Baron MD MSc, S., Chadderdon, S., Khalique, O. K., Gilbert H.L. Tang, MD, MSc, MBA, Taramasso, M., Grayburn, P. A., Badano, L., Leipsic, J., Lindenfeld, J., Windecker, S., … Hausleiter, J. (2023). Tricuspid Valve Academic Research Consortium Definitions for Tricuspid Regurgitation and Trial Endpoints. Journal of the American College of Cardiology. https://doi.org/10.1016/j.jacc.2023.08.008
- ↑ 6.0 6.1 Hahn, R. T., Makkar, R., Makar, M., Davidson, C., Puthamana, J., Zahr, F., Chadderdon, S., Fam, N., Ong, G., Yadav, P. K., Thourani, V. H., Vannan, M. A., Tchétché, D., Dumonteil, N., Bonfils, L., Lepage, L., Smith, R., Grayburn, P. A., Webb, J. G., … Kodali, S. (2024). EVOQUE tricuspid valve replacement system: State-of-the-art screening and intraprocedural guidance. JACC. Cardiovascular Interventions, 17(18), 2093–2112. https://doi.org/10.1016/j.jcin.2024.07.034
- ↑ Andreas, M., Burri, H., Praz, F., Soliman, O., Badano, L., Barreiro, M., Cavalcante, J. L., de Potter, T., Doenst, T., Friedrichs, K., Hausleiter, J., Karam, N., Kodali, S., Latib, A., Marijon, E., Mittal, S., Nickenig, G., Rinaldi, A., Rudzinski, P. N., … Leclercq, C. (2024). Tricuspid valve disease and cardiac implantable electronic devices. European Heart Journal, 45(5), 346–365. https://doi.org/10.1093/eurheartj/ehad783
- ↑ Salter, B., Tang, G. H. L., Hahn, R. T., Lala, A., Adams, D. H., Asgar, A., Borger, M. A., Fam, N. P., Ho, E. C., Khera, S., Kini, A. S., Latib, A., Lee, A. P. W., Lerakis, S., Lurz, P., Safi, L. M., Sorajja, P., Stephan von Bardeleben, R., Praz, F., … So, K. C. Y. (2026). A contemporary look at the landscape of treatment of tricuspid regurgitation: A review: A review. JAMA Cardiology, 11(1), 98–106. https://doi.org/10.1001/jamacardio.2025.4337