Rapid progress in the field of interventional cardiology has caused research in
the field of morphometry of the heart to be in constant demand [7&#8211;10, 12]. In
this study, performed on a group of 75 adult human hearts, the authors have
attempted to assess the form and number of the main and accessory cusps in
the tricuspid valve. We have classified particular forms into 8 groups, depending
on the number of cusps and we have divided the cusps into 3 main groups,
depending on the support of the chordae tendineae

Grzybiak, M

Hreczecha, J

Kosiński, A

Skwarek, M

English

Via Medica Journals

Folia Morphol. Vol. 63, No. 3, pp. 319–324Copyright © 2004 Via MedicaISSN 0015–5659www.fm.viamedica.plO R I G I N A L  A R T I C L E319Address for correspondence: Magdalena Skwarek, Department of Clinical Anatomy, Medical University, ul. Dębinki 1, 80–211 Gdańsk,Poland, tel/fax: +48 58 349 14 20, e-mail: mskwarek@mediclub.plNotes on the morphology of the tricuspidvalve in the adult human heartMagdalena Skwarek, Marek Grzybiak, Adam Kosiński, Jolanta HreczechaDepartment of Clinical Anatomy, Medical University, Gdańsk, Poland[Received 10 January 2004; Revised 23 March 2004; Accepted 24 March 2004]Rapid progress in the field of interventional cardiology has caused research inthe field of morphometry of the heart to be in constant demand [7–10, 12]. Inthis study, performed on a group of 75 adult human hearts, the authors haveattempted to assess the form and number of the main and accessory cusps inthe tricuspid valve. We have classified particular forms into 8 groups, dependingon the number of cusps and we have divided the cusps into 3 main groups,depending on the support of the chordae tendineae.Key words: tricuspid valve, human heart, right ventricle, cusp,commissure, morphologyINTRODUCTIONDespite intense interest in cardio-anatomy, thereare many issues to be examined with great care. Theproblem of the morphology of the atrioventricularostia is still an open question. The tricuspid valve,which, in the light of existing research, is a hetero-geneous structure with great variability in its struc-ture, has remained unexamined. However, there issome research which describes the structure of thetricuspid valve, although authors differ in their atti-tudes toward this. The number of cusps, their con-figuration and their size are still controversial. Oneof the first who paid attention to the presence ofaccessory cusps was Tandler in 1913 [16]. Accessorycusps were also described by Testut and Latarjet in1923 [17] and Jastrzębski in 1926 [5], but their de-scriptions are based on a limited number of cases.Descriptions of the chordae tendineae and the lo-calisation of the papillary muscles differ from onestudy to another. The dynamic progress of thera-peutic and diagnostic cardio-invasive proceduresimplies a marked rise in interest in studies of cardiacanatomy and it is reasonable, therefore, to resumeresearch on the tricuspid valve.MATERIAL AND METHODSThe study material consisted of 75 formalin-fixedadult human hearts, between 27 and 79 years ofage and of both sexes, in which no macroscopic de-velopmental failures and pathological changes hadbeen found. The hearts were opened by dissectionof the wall of the right atrium between the ostia ofboth venae cavae and then along the right marginof the right ventricle. The walls of the right part ofthe heart were drawn aside to reveal the valvularapparatus. We estimated the number of cusps, theirlocalisation, morphology; their width and heightwere measured.RESULTSUsing as the criterion for division the number ofcusps of the tricuspid valve, we established 5 types(Table 1). The most common was a 4-cuspidal struc-ture consisting of 3 main cusps and one accessorycusp (CAc). This form appeared in 40% of cases inthe group of hearts studied (Fig. 1). On the basis ofanalysis of the localisation of the accessory cuspswe established 3 subtypes: 1) the accessory cusp lo-calised between the posterior cusp (CP) and the sep-320Folia Morphol., 2004, Vol. 63, No. 3tal cusp (CS) — this configuration was the most fre-quent subtype of the 4-cuspidal structure (25.3%);2) the accessory cusp localised between the anteriorcusp (CA) and the CS — this subtype was rare andappeared in 9.3%, and 3) the accessory cusp loca-lised between CA and CP, which occurred in 5.3%of cases.An unusual form of the tricuspid valve wasa 5-cuspidal form with 2 accessory cusps localised be-tween CA and CS and between CS and CP. This vari-ant appeared in 33.3% of the hearts analysed (Fig. 2).Another unusual type observed by us consistedof 6 cusps — 3 main cusps and 3 accessories. Thisappeared in 13.3% of the hearts analysed (Fig. 3).In only a small percentage (9.3%) of the heartsstudied did we observe the “typical” form of the tri-cuspid valve without accessory cusps (Fig. 4).Our analysis yielded an assessment of the rarestconfiguration of all , a 7-cuspidal form of the tricus-pid valve. This appeared in only 4% of the heartsstudied. In this type the accessory cusps appeared inthe following configuration: 2 between CS and CP,one between CS and CA and the last one betweenCA and CP (Fig. 5).We classified the accessory cusps into 2 groupsaccording to Grzybiak’s categories for the mitral valve[2–4] and those of Szostakiewicz-Sawicka [14] andSzostakiewicz-Sawicka and Grzybiak [15]. The morefrequent were spurious cusps (supported by chordaetendineae arising from one apex of the papillarymuscle — 58.6% of the hearts studied) (Fig. 6) andthe less frequent group consisted of real accessorycusps (supported by chordae tendineae arising from2 apices of papillary muscle — 41.3% of the heartsstudied) (Fig. 7).Table 1. Frequency of particular types and subtypesof tricuspid valveType Number Occurrence in studiedof cusps group [%]1 3 9.32 4 36.15Subtype A 23.8Subtype B 7.8Subtype C 4.53 5 33.34 6 13.35 7 4.1Subtype A 2.6Subtype B 1.3CA — anterior cusp, CP — posterior cusp, CS — septal cusp, subtype A — theaccessory cusp localised between CP and CS, subtype B — the accessory cusplocalised between CA and CS, subtype C — the accessory cusp localised be-tween CA and CPFigure 1. Subtypes of four-cuspidal form of tricuspid valve.A. CAc is localised beetween CS and CP; B. CAc beetween CAand CS; C. CAc beetween CA and CP. CAc — accessory cusp,CS — septal cusp, CP — posterior cusp, CA — anterior cusp.321Magdalena Skwarek et al., Tricuspid valve morphology in the human heartFigure 3. Six-cuspidal form of tricuspid valve. Abbreviations asin Figure 1.Figure 2. Five-cuspidal form of tricuspid valve. Abbreviations asin Figure 1.Figure 5. Seven-cuspidal form of tricuspid valve. Abbreviationsas in Figure 1.Figure 4. ”Typical” tricuspid form of tricuspid valve. Abbrevia-tions as in Figure 1.The shape analysis of the cusps of the tricuspidvalve showed that all were triangular. Analysis oftheir morphology, in particular, showed little differ-entiation. However, the CS usually resembled a tri-angle with its base longer than its height, while forthe CP the relationship between the base and heightof the triangle was inverted. We noted that this re-lationship was variable in CA and accessory cusps.The height of cusp was defined, according toSzostakiewicz-Sawicka [14], Szostakiewicz-Sawickaand Grzybiak [15] and Grzybiak [2–4], as the dis-tance between the base and the apex of the cusp.This dimension was termed the width of the cuspby Łukaszewska-Otto [11], but we used the termi-nology of Grzybiak and Szostakiewicz-Sawicka, asthis corresponds to the convenient terms for trian-322Folia Morphol., 2004, Vol. 63, No. 3gles, to which the cusps of the valve are compared,while Łukaszewska’s terminology would throw thisinto confusion. The measurement analysis of sever-al cusps led us to arrive at the conclusion that theheight of CA is greater than that of the others.CP was usually lower than CA, but the lowest was CS.Accessory cusps were always lower than the mainones (Table 2).The mean height of CA was 23.88 ± 0.85 mm,the mean height of CP was 21.35 ± 0.90 mm, theheight of CS — 18.33 ± 0.98 mm and the meanheight of the accessory cusps 14.88 ± 0.99 mm.During analysis of the accessory cusps we observedthat the highest was localised between CA and CP,that between CS and CP was lower and the lowestFigure 7. Real CAc. Abbreviations as in Figure 1.Figure 6. Spourious CAc. Abbreviations as in Figure 1.Table 2. Height of particular cusps of the tricuspid valveCusp Mean height [mm] SDAnterior cusp 23.88 0.85Posterior cusp 21.35 0.90Septal cusp 18.33 0.98Accessory cusp 14.88 0.99was between CA and CS. We observed sex-associat-ed differences in the size of the accessory cusps.Cusps in male hearts were significantly higher thanin female hearts (21.92 ± 0.92 mm in male heartsvs. 19.61 ± 0.88 mm in female ones). This problemrequires further investigation.323Magdalena Skwarek et al., Tricuspid valve morphology in the human heartWe evaluated the commissure localised betweenthe cusps. We defined commissure as that part ofvalve contained between the annulus fibrosus andthe peak of the intercuspidal incision. We observedcommissure in a majority of the hearts examined.The length of the commissure was 7.11 ± 0.97 mm)and no significant difference was observed in thesize of particular commissure. This problem will formthe subject of another study.DISCUSSIONThe results of our study show great variability ofthe right atrioventricular valve. Only in a small per-centage of the hearts examined was the valve nor-mally termed the “tricuspid” composed of 3 cuspsand instead with multi - cuspidal forms prevailed.This relation was also studied by Szostakiewicz-Sawicka [14], Łukaszewska-Otto [11] and Kosińskiet al. [6]. Szostakiewicz-Sawicka performed herstudies on a group of 30 human hearts. The 3-cus-pidal form appeared in 30%, the 4-cuspidal form in46.6% and the 5-cuspidal form in 23.3%. In a studyof Łukaszewska-Otto [11] performed on a group of130 human hearts the 3-cuspidal form appeared in8.46% and the 4-cuspidal form in 36.15%. The ac-cessory cusp was localised between CP and CS in23.8%, between CA and CS in 7.8% and betweenCA and CP in 4.5%. The 5-cuspidal form appearedin 33.85%, the 6-cuspidal form appeared in 17.69%and both the 7 and 8-cuspidal forms appeared in1.53%. The results of Kosiński et al. [6] were as fol-lows: the 3-cuspidal form appeared in 9.1%, the4-cuspidal form appeared in 38.2%, the 5-cuspidalform in 32.7%, the 6-cuspidal in 16.7%, and the7-cuspidal in 3.6% of cases.It is notable that Szostakiewicz-Sawicka and Grzy-biak [15] compared the structure of the cusps of theright atrioventricular valve in 84 hearts of other pri-mates and the author ascertained the dependenceof the form of the valve on phylogenetic evolution.The divergence of our results with those present-ed above may be due to the fact that Szostakiewicz--Sawicka used human hearts as a comparative groupwith 84 monkey hearts.Our results are convergent within the 3 to7-cuspidal form range with the results of Łukasze-wska-Otto [11] and Kosiński et al. [6]. We did notobserve an 8-cuspidal form, which can be explainedby its rare occurrence.The authors of the research presented above didnot compare the shape and size of the accessorycusps.Commissure of the tricuspid valve were describedby Rocache [13] and commissure of the mitral valveby Grzybiak [2]. Our criteria for the assessment ofcommissure are compatible with both these studies.Grzybiak increased understanding of commissure, asdid Rocache, and coined the term “commissuralzone”. The term “commissure” does not exist in Nom-ina Anatomica [18] but has been introduced into prac-tice by clinicians [1].It is a well known fact that endocarditis causesfusing of the valvular cusps, implying enlargementof the distance between the annulus fibrosus andthe intercuspidal incision. There is little data on thisand what does exist is fragmentary. It seems rea-sonable to calculate the height of the commissurein normal hearts in order to assess the criteria fordistinguishing the normal and the pathological— valvular stenosis.It would also be reasonable to qualify the rela-tionship between the height and width of the com-missure and their number.REFERENCES1. Glover RP, Davila JC (1961) The surgery of mitral steno-sis, Grune Stratton, New York, London.2. Grzybiak M (1988) Morfologia zastawki dwudzielneju człowieka dorosłego w świetle badań własnych. Roz-prawa habilitacyjna Akademia Medyczna, Gdańsk.3. Grzybiak M, Szostakiewicz-Sawicka H (1981) Tendinouscords of the heart in primates. Arch Ital Anat Embriol,86: 281–285.4. Grzybiak M (1992) Rodzaje strun ścięgnistych w lewejkomorze serca u człowieka w świetle badań własnychi innych autorów. Ann Acad Med Gedan, 22: 121–127.5. Jastrzębski C (1926) O zmienności kształtu zastawkitrójdzielnej serca i o otworach wrodzonych w jejpłatkach. Kosmos, Seria A, Biologia, 51: 191.6. Kosiński A, Kuta W, Grzybiak M, Ciszkowicz M, Ka-miński R (2000) Morfologia zastawki trójdzielnejw sercu człowieka dorosłego i innych naczelnych. PrzegMed, 2: 80.7. Kozłowski D, Krzymińska-Stasiuk E, Koźluk E, Krupa W,Grzybiak M, Świątecka G, Walczak F (1999) Ocena ana-tomiczno-echokardiologiczna niedomykalności zastawkitrójdzielnej u chorych ze stymulacją serca. Badaniawstępne. Folia Cardiol, 6: 86.8. Kozłowski D, Grzybiak M (2002) The type of pacinglead and the degree of morphological changes in thepermanently paced heart — a morphological study.Folia Morphol, 61: 184.9. Krupa W, Kozłowski D, Derejko P, Świątecka G, Grzy-biak M (2001) Tricuspid regurgitation in permanentpacing — preliminary report. Europace, 79–84.10. Krupa W, Kozłowski D, Grzybiak M, Świątecka G (2002)Clinical anatomy of the tricuspid valve insufficiency inpermanently paced patients. Folia Morphol, 61: 185.324Folia Morphol., 2004, Vol. 63, No. 311. Łukaszewska-Otto H (1970) Zmienność budowy zastaw-ki przedsionkowo-komorowej prawej u człowieka. Roz-prawa habilitacyjna. Akademia Medyczna, Warszawa.12. Piszczatowska G, Piwko G, Kozłowski D, Kosiński A,Ćwieluch E, Grzybiak M, Karmoliński A, Orpich M, Rosz-kiewicz A (1999) Anatomia zastawki trójdzielnej w as-pekcie stałej stymulacji serca. Folia Cardiol, 6: 27.13. Rocache M (1967) La commisurotomie tricuspide.These pour le doctorat en medecine. Faculté de méde-cine de Paris, Paris.14. Szostakiewicz-Sawicka H (1969) Zastawka przedsion-kowo-komorowa prawa u naczelnych. Rozprawa dok-torska. Akademia Medyczna, Gdańsk.15. Szostakiewicz-Sawicka H, Grzybiak M (1981) Zgodnośćrozwoju osobniczego niektórych cech budowy sercaz przypuszczalnym kierunkiem ich rozwoju w antro-pogenezie. Morfologia, podręczniki, skrypty AWF.Seria: Monografie. Poznań 199: 9–16.16. Tandler J (1913) Anatomie des Herzens. In: Handbuchder Anatomie des Menchen. Van Bardeleben K (ed.).G. Fischer, Jena 84–90.17. Testut L, Latarjet A (1948) Traite d’anatomie humaine.Vol. II. G. Doin Cie, Paris.18. Współczesne Mianownictwo Anatomiczne (2002)I Ed., Czelej, Warszawa

Notes on the morphology of the tricuspid valve in the adult human heart

https://journals.viamedica.pl/folia_morphologica/article/download/16231/12869

Notes on the morphology of the tricuspid valve in the adult human heart

Abstract

Similar works

Full text

Available Versions

Via Medica Journals