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2/12/2018
1
Roberto M Lang, MD
Imaging the Tricuspid Valve
M-mode
2D Echocardiography
Anterior
Septal
Anterior
Septal
SeptalPosterior
2/12/2018
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THE TV ON 3D ECHO
S
A PA
S
P
RV perspective RA perspective
THE TRICUSPID VALVE: ADDED VALUE OF 3D IMAGING
x
y
x
y
z
2D 3D
< 5% of pts ~ 85% of pts
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THE NORMAL TRICUSPID VALVE COMPLEX
1. Three leaflets Anterior Septal Posterior
2. Fibrous annulus3. Chordae tendinae4. Papillary muscles5. RA myocardium6. RV myocardium
Courtesy Dr. Stephen P. Sanders, Professor of Pediatrics (Cardiology),
Harvard Medical School
2/12/2018
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HOW MANY LEAFLETS DOES THE TRICUSPID VALVE HAVE?
• 36 adult human hearts • # leaflets vary from 3-7• Extra leaflets are called
“accessory leaflets”• Accessory leaflets are
common
Typical three-leaflets
Seven leaflets (4 accessory leaflets)
16.6%
16.6%
Lama P, et. al. Anat Sci Int. 2016 Mar;91(2):143-50.
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AMBIGUITY OF LEAFLET IMAGED ON 2D
SA
P
S A
P
RV inflow view
AMBIGUITY OF LEAFLET IMAGED ON 2D
SA
P
SA
P
Apical4-chamber
view
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Basal SAX view
Anteriorleaflet
Aorta and single leaflet
Posteriorleaflet
P
A
S
Anteriorleaflet
Aorta and two leaflets
Aorta
Aorta
Anterior or septal leaflet
Posterior or anterior leaflet
P
A
S
Posteriorleaflet
Septalleaflet
LVOT/septum and two leaflets
LVOT
PS
A
J Am Soc Echocardiogr 2016;29:74-82.)
Anteriorleaflet
Septal or posterior leaflet
S
P
A
RVIF view
Septalleaflet
Septalleaflet
P
AS
PA
S
Posteriorleaflet
2D view without septum 2D view with septum
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Post LVAD study
13Presentation Title Here |
RV inflow view
S
PA
RV inflow view 2
S
PA
S
A
P
A
14Presentation Title Here |
RV inflow view #1 RV inflow view #2
S
A
Mild TR Severe TR
S
A
P
A
Post LVAD study
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Septal leaflet
Anterior or posterior leaflet
Anteriorleaflet
SP
A
5-chamber view
LVOT
Apical view
Coronarysinus
A
P S
Posterior leaflet
4 CV
J Am Soc Echocardiogr 2016;29:74-82.)
MECHANISMS OF TRICUSPID REGURGITATION
Primary(or “Organic”)
Secondary (or “Functional”)
Intrinsic abnormalityof the valve apparatus
TV annular dilatation, RV dilatation and papillary muscle displacement
70-85%* of TR15-30%* of TR
Antunes MJ, Barlow JB, Heart 2007
2/12/2018
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Primary/Organic TR –PPM/ICD Device Location
17
RV inflow
A4C
ICD inserted and echo performed 8 days later
26 year-old with dilated cardiomyopathy on the transplant list
RV perspective
RA perspective
Severe TRA4C
RV inflow
Pre-ICD
Post-ICD
P-S COMMISSURE:
CORRECT POSITION
A:
Postero-septal Antero-posterior Middle Antero-septal
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• Primary (Organic) TR – Pacemaker/ICD89 year-old man with right heart failurePast medical history: CAD, MV repair, TAVI in 2009• Permanent pacemaker implantation post TAVI for bradycardia
2/12/2018
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PACEMAKER ADHERENCE
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FUNCTIONAL TRICUSPID REGURGITATION
Chronic PE, Lung disease
RV ischemia, VOL, CM
Left-sided valve disease
Atrial fibrillation
L-R shunt
FTR
Dreyfus G. J Am Coll Cardiol 2015;65:2331–6
TA dilatationRV enlargementPM displacement
TV tethering
70-85%* of TR
TRICUSPID VALVE ≠ MITRAL VALVE
Different valve orifices Different subvalvular apparatuses Different ventricles
Yet TR and MR are assessed in similar ways
Tricuspid valve Mitral valve
≠
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JASE 2017
GRADING OF TRICUSPID REGURGITATION SEVERITY
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TRICUSPID VALVE ≠ MITRAL VALVE
TR IS LOAD DEPENDENT
64 year-old man with a NICM
LVEF – 20%
Functional TR
28Presentation Title Here |
Tricuspid annulus dilatation may be a more reliable indicator of TV pathology than degree of regurgitation
Good correlation between TA diameter and TR regurgitant volume
46 mm
TR varies depending on preload, afterload, RV function
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TRICUSPID VALVE ≠ MITRAL VALVE
Pre and post peritoneal dialysis
Normal tricuspid annular dimension
TRICUSPID VALVE ≠ MITRAL VALVE
TA = 51 mm TA = 55 mm
TopilskyY et. al. Circulation 2010;122
TR depends on respiratory
phase
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Functional TR and annular dilatation
31Presentation Title Here |
The annulus is dilated if it measures1. > 40 mm or > 21 mm/m2 on 2D
transthoracic echocardiography–Apical 4-chamber view–In diastole
2. > 70 mm on direct intraoperative measurement
ACC/AHA Guidelines for management of VHD JACC 2014
ESC/EACTS Guidelines for management of VHD EHJ 2012
IMPORTANCE OF THE TRICUSPID ANNULUS
Dreyfus et al. Ann Thorac Surg, 2005
Despite a sicker MV +TV repair group…
Survival @ 10 years 90.3% 85.5% p=NS
Grade III-IV TR 1% 34% p<0.001
Class III-IV CHF 0% 14% P < 0.01
MV + TV repair MV repair only
Performing tricuspid annuloplasty based on TA dilatation rather than TR degree results in improved surgical outcome
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•TA size measured by 2D echocardiography should be interpreted with caution because it is underestimated by both 2D TTE and TEE.
ROLE FOR 3D ECHOCARDIOGRAPHY
• Better approximation of septal-lateral dimension • Also allows measurement of antero-posterior dimension
Addetia K, Muraru D, Veronisi F, Badano LP, Lang RM et. al. work in progress
2/12/2018
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Software-generated annulus
Long-axis dimension
RV focused view dimension
Traditional 4-chamber dimension
Short-axisdimension
Addetia K, Muraru D, Veronisi F, Lang RM, Badano LP et. J Am Coll Cardiol (in press)
On the horizon…
3D Echo
TRICUSPID ANNULUS
Saddle-shaped• High points antero-posterior
• Low points medial-lateral
Ellipsoid shape
Courtesy F. Veronesi, PhD.
Ton-Nu Circulation. 2006
RA
Apex
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FUNCTIONAL TRICUSPID REGURGITATION
TA dilatation occurs mostly along the RV free-wall Septal portion of the tricuspid annulus relatively fixed
Dreyfus et al. ATS 2005
FUNCTIONAL TRICUSPID REGURGITATIONNormal Functional TR
Non‐planarity angle = 158° Non‐planarity angle = 173°
With worsening TR, the annulus becomes larger, rounder and flatter
Taramasso M et al. J Am Coll Cardiol 2012
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MECHANISMS OF TRICUSPID REGURGITATION
TR s highly dependent on annular dilatation, with significant TR occurring with only 40% dilatation, whereas it was seen at 75% dilatation in vitro MV studies. i.e. the TV leaks earlier that the MV Spinner EM. Circulation 2011
THE ACC/AHA 2014 GUIDELINES
ACC/AHA Guidelines for management of VHD JACC 2014
ESC/EACTS Guidelines for management of VHD EHJ 2012
TA dilated if >40 mm in apical 4-chamber view
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MECHANISMS OF TRICUSPID REGURGITATION
Pre-operative TR, TV tethering distance and TV tethering area were independent predictors of residual TR after annuloplasty. Tethering distance 0.76 cm and tethering area 1.63 cm2 had the best AUC (0.88 and 0.87 respectively)
Fukuda Circulation 2005
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MECHANISMS OF TRICUSPID REGURGITATION
RV basal dimensionRV length
Group (N) Controls (99) Id FTR (141) PHTN FTR (140)TR None Matched for ERO
sPAP Normal <50 mmHg ≥ 50 mm HgAssociations: Controls Aging, Afib
TA Normal
Tenting Normal Normal
RV Base Normal
RV Length Normal Normal
Remodeling -- Conical EllipticalTopilskyY, Circ Cardiovasc Imaging. 2012;5:314-323
MECHANISMS OF TRICUSPID REGURGITATION
Tenting volume >2.3 cm3
Min SY et al. Eur Heart J 2010
TV tenting volume by 3DE (accounting for both enlarged annulus area and leaflet tenting) is the major determinant
of residual functional TR after annuloplasty
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NEW DIRECTIONS: EVALUATION OF FTR A MORE COMPREHENSIVE APPROACH
Dreyfus et. al. JACC 2015
ON THE HORIZON…
Muraru D…et. al. European Heart Journal Cardiovascular Imaging
2/12/2018
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BEWARE… THE ULTRASOUND BEAM OFTEN ELICITS FINDINGS THE HISTORY
AND PHYSICAL EXAM CANNOT…
Thank you!