Three-dimensional transesophageal echocardiography incremental value in a case with a rare combination of tricuspid valve prolapse and rheumatic mitral valve stenosis

IntroductionThe tricuspid valve (TV) is a complex structure (Lamers et al. (1995) [1]). The most common cause of pathologic tricuspid regurgitation is functional, due to annular dilatation with normal leaflet morphology (Sagie et al. (1994) [2]). Myxomatous disease of the tricuspid valve is often associated with mitral valve involvement but isolated tricuspid prolapse has been rarely reported (Tei et al. (1983) [3]). Unlike the common combination between rheumatic mitral valve stenosis and functional tricuspid regurgitation, to the best of our knowledge, this is the first case of such combination between tricuspid valve prolapse and rheumatic mitral valve stenosis reported with three-dimensional transesophageal echocardiography (3D-TEE).Case presentationWe are presenting a 43-year-old female patient that had dyspnea on effort NYHA class III. A transthoracic echocardiography showed severe rheumatic mitral valve stenosis with severe tricuspid regurgitation. A routine preoperative 2D-transesophageal echocardiography (2D-TEE) showed severe rheumatic mitral valve stenosis with severe tricuspid regurgitation due to prolapse of one of the tricuspid valve leaflets. 3D-TEE showed prolapse of the medial half of the posterior leaflet of the tricuspid valve. These findings were confirmed during surgery and had led to a change in the surgical plan from traditional mitral valve replacement with tricuspid valve annuloplasty, to mitral valve replacement with tricuspid valve anatomical repair.ConclusionThe tricuspid valve is a complex structure. 2D-TTE and TEE is not usually enough for complete delineation of the anatomy and pathology of the tricuspid valve. 3D-TEE has an incremental value in providing informative en-face view of the three leaflets of the tricuspid valve that facilitates precise determination of its anatomy and pathology. This is a rare case of unusual combination between tricuspid valve prolapse and rheumatic mitral valve stenosis.