Getting a good apical window is not always easy, and that can be frustrating when you are specifically trying to assess tricuspid regurgitation. This is particularly relevant in nephrology, where TR often becomes an important part of the evaluation in patients with volume overload and systemic venous congestion.

When the apical window is poor, it helps to step back and try a different approach. If the parasternal window is reasonably good, the tricuspid valve can often still be interrogated using the right ventricular inflow view.

As you know, the tricuspid valve is not seen in the standard parasternal long-axis view. To bring it into view, start from the usual parasternal position and gently tilt the transducer toward the patient’s right hip. You can think of the probe like a flashlight: rather than pointing it straight across the heart, you are angling it downward to illuminate a different structure.

A few small adjustments in tilt and rotation are often needed, but with a little patience, the right atrium, right ventricle, and tricuspid valve usually come into view.

The figures below illustrate the anatomy of this modified view and how those structures correspond to what you see on the ultrasound screen.

The following sonographic images illustrate this view. If a pacemaker lead is present, seeing it coursing through the valve can serve as a helpful clue that you are indeed imaging the right heart.

This image is from a patient with moderate to severe tricuspid regurgitation. From this view, you can also obtain a continuous wave Doppler tracing, which allows estimation of the right ventricular systolic pressure (RVSP). However, be mindful that achieving optimal parallel alignment between the regurgitant jet and the ultrasound beam is not always possible in this view, so RVSP can be underestimated compared to measurements obtained from the apical window.

Below: another patient with tricuspid regurgitation – color and continuous wave Doppler of TR jet.

In relatively thin individuals, inferior vena cava can be seen from this view with slight rotation of the probe and/or going one intercostal space lower. Here is an example.

Below: Coronary sinus thrombus seen in this view

Below: Large pericardial effusion in this view. If you look closely, you can also appreciate right ventricular diastolic collapse.