TR is a common echocardiographic finding. Nath and colleagues evaluated 5223 patients who had undergone echocardiography at laboratory within a 4-year period. The TR incidence was 88.5%, with 15.5% having moderate or greater TR Type TR - Primary - Secondary/Functional (MC) (80-85%)Etiology of FTR Left heart disease Chronic Pulmonary Disease Primary pulmonary Hypertension. FTR has poor prognosis if it is not treated- leads to irreversible right ventricular dysfunction and failure.
There is a strong impact of TR on clinical outcome. Significant TR is associated with poor prognosis in patients with mitral stenosis after percutaneous balloon valvuloplasty and with a reduction in exercise capacity after mitral valve surgery. A significant increase in mortality among patients with moderate and severe TR has been reported, which was independent of left ventricular ejection fraction or pulmonary artery pressure. In 60 patients with flail tricuspid leaflet due to trauma, significant increases in atrial fibrillation, heart failure, and death were observed. TR was also an independent predictor of increased mortality in 1400 patients with left ventricular systolic dysfunction. According to a review of 5223 patients, the 1 year survival rate was about 90%- no/mild TR, 79% for moderate TR, 64% for severe TR, independent of age. Sagie A. JACC,1994;24:696–702; Nath J. J Am Coll Cardiol 2004;43:405–409
Matsuyama and colleagues followed up 174 patients without FTR repair for a mean of 8.2 years. During follow-up, 16% had developed FTR of grade 3 or more. Dreyfus and colleagues corrected the FTR in 311 patients according to the anatomic criteria (intraoperative diameter > 70 mm). After a mean follow-up of 4.8 years, the FTR grade had changed from 0.88 to 0.36 in the treated patients and from 0.82 to 2.07 in the untreated patients (P<.001), with 48% of the patients having an increase to FTR grade 2 or more. Michal Smid et. al Cardiology Research and Practice, 2010, 5. Dreyfus et al .Ann Thorac Surg.2005;79:127-32. Matsuyama et al. Ann Thorac Surg. 2003;75:1826-8.
One small study on only 39 patients showed that in addition to tricuspid valve tethering, left ventricular as well as right ventricular function and pressure influence repair durability. Recent data from the Cleveland clinic on 2000 patients report a high recurrence rate of significant TR years after surgery, irrespective of the mode of repair. By 3 months after surgery, 34% of patients had moderate or severe TR, which increased to 45% of patients at 5 years. Fakuda et al. Circulation 2006:114:I-582–I-587. Navia Jl et al. J Thorac Cardiovasc Surg 2010;139:1473–1482.
Color doppler- visual assessment of color jet area is a quick intial screeningMeasurement of Vena contracta-Regurgitation jet areaEROA and regurgitation volume measurement - PISA method – laborious.PISA and vena contracta corelate well in TR, VC prefered.
Doppler examination-CW- used for estimation of RVSP- Maximum TR jetvelocity measured and pressure calculated by Bernoulli equation(p=4V2).PW confirmed severe TR- as jet velocity > 1m/s
Vena contract width > 6.5mm Annulus dilatation > 40mm or inadequate cusp coaptation Regurgitation volume > 45 mL Increased tricuspid inflow velocity > 1m/s ERO > 0.4cm2 Color flow regurgitant jet area > 30% of RA area. Systolic flow reversal in the hepatic vein. The ECHO Manual
Tricuspid valve repair in conjunction with mitral valve surgery is beneficial for severe TR and should be considered for less than severe TR when there is dilated annulus (>40mm) or pulmonary hypertension. Tricuspid valve repair consider when annulus diameter is twice the normal.
Many patients with normal annular diameter has TR grade 1or 2. Many patients can have significant FTR even if the TA dimensions are within the normal range. Normal TA – 25-28mm TA diameter cant be the only determinant indication for surgery.
Right ventricular longitudinal/systolicfunction.Measure at tricuspid lateral annulus.Normal Range- 1.5-2.0 cm,Value < 1.6 consider as abnormal. Event free survival rate according to TAPSE in CHF
TV is complex structure With 2D Echo it is difficult to see all three leaflet Anwar et al found that both the septal and anterior leaflets were visualized in 100% of patients in the parasternal short-axis and apical four-chamber views. The posterior leaflet was seen only in the parasternal short-axis view (92% of patients), and the second leaflet seen in this view was variable (septal in 48%, anterior in 52%). Difficult to assess coaptation of 3 leafletsAnwar et al. Int J Cardiovasc Imaging. 2007;23:717–24.
Real-time 3D echocardiography allows for rapid acquisition and viewing of high-quality images. 3DE can visualize the valve from the right atrial or “surgeon’s” view, so that all three leaflets may be viewed. The ability to visualize all three tricuspid leaflets simultaneously is a major advantage of 3DE. Badola LP et al. Eur J Echocardiogr. 2009;10:477–84.
TR is common echocardiographic finding in general population Prognosis of severe TR is not good, among LHF patients it is independent predictor of event free and overall survival. Diagnosis and thorough assessment of TR is key to success Annular diameter can`t be only parameter to be consider for surgical intervention. Durability of T annuloplasty need to checked Prophylactic TR intervention during other cardiac surgery is debatable. Randomized controlled trials need to answer these issues