LAUSR

Cross-sectional 2D transthoracic echocardiographic (TTE) images of pulmonary and tricuspid valves depicting three leaflets simultaneously are seldom visualized in adults and are deemed to be impossible to obtain using 2D TTE. Recently, therapeutic advancements have been achieved for different pathologies of both valves. However, anatomical obstacles due to retrosternal placement and crescent shape of the right ventricle and neighboring of the left upper lung lobe to the pulmonary trunk detain comprehensive evaluation of tricuspid and pulmonary valves. Generally, short-axis en-face views cannot be obtained using 2D TTE. Lack of this morphological data requires complimentary advanced imaging techniques. However, some cardiovascular diseases yield extensive remodeling, wherein unexpected anatomical structures or infrequent projections of ordinary structures can be visualized. Pulmonary arterial hypertension (PAH) offers an opportunity to obtain these rare views, which is facilitated by dilatation of the right ventricle and pulmonary trunk. Here, we present exceptional cross-sectional en-face views of pulmonary and tricuspid valves in patients with PAH of various etiologies. Figure 1 shows en-face views of the pulmonary valve in patients with concomitant chronic thromboembolic pulmonary hypertension and residual PAH following congenital heart disease surgery (Video 1), idiopathic PAH (Video 2), and secondary PAH due to unoperated ventricular septal defect and patent ductus arteriosus, respectively. Figure 2 shows en-face views of the tricuspid valve in patients with pulmonary veno-occlusive disease, residual PAH following the closure of patent ductus arteriosus (Video 3), and secondary PAH due to unoperated ventricular and atrial septal defects, respectively. Due to abovementioned anatomical obstacles, it is extremely difficult to obtain cross-sectional en-face images of pulmonary and tricuspid valves using 2D TTE. Unfortunately, echocardiography textbooks lack sample representative images. While 3D echocardiography has become a valuable tool to overcome this drawback, we must realize that extensive remodeling of the right side of the heart in certain diseases may facilitate 2D visualization of these unexpected views. Literature is also limited about this issue. En-face view of the pulmonary valve using 2D TTE has been reported just once (1). According to a recent paper attempting to obtain en-face view of the tricuspid valves, E-1