Tricuspid regurgitation and echocardiography

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Tricuspid regurgitation,

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Tricuspid regurgitation and echocardiography

  1. 1.  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.
  2. 2.  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
  3. 3.  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.
  4. 4.  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.
  5. 5.  Detect TR Estimate severity Assess pulmonary HTN RV function LV function Tricuspid annulus
  6. 6. Color doppler- visual assessment of color jet area is a quick intial screeningMeasurement of Vena contracta-Regurgitation jet areaEROA and regurgitation volume measurement - PISA method – laborious.PISA and vena contracta corelate well in TR, VC prefered.
  7. 7. 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
  8. 8.  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
  9. 9.  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.
  10. 10.  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.
  11. 11. 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
  12. 12.  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.
  13. 13.  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.
  14. 14. CM BM:LVEDV: 115 ml;LVESV: 38 ml LVEDV: 99 ml;LVESV: 43 mlFE: 66% FE: 60%Gmed Mitrale: 6 mmHg GM Mitrale: 3.8 mmHgAortic Velocity: 2 Aortic Velocity: 1.1Tricuspid GM: 1 mmHg Tricuspid GM: 0.8 mmHgTricuspid annulus D: 22 mm Tricuspid annulus D: 24 mmTR: MILD TR: MILDTAPSE: 1.5 cm TAPSE: 2.4cmVolume RV: 6.7 Dya, 6.4 Sys Volume VD: 16 Dya, 7 SysDG MG:LVEDV: 115 ml;LVESV: 64 ml TR- MILDFE: 55% PAP-normalGmed Mitrale: 1,2 mmHgAortic Velocity: 0.9 HN:Tricuspid Gmed: 0.7 mmHg TR- severeTricuspid annulus D: 19mm Admitted in ITU.TR: MILDTAPSE: 2.8cm SM:Volume VD: 27 Dya, 14,5 Sys Not traced
  15. 15.  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

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