PREOPERATIVE ECHOCARDIOGRAPHIC CLUES FOR THE REPAIR OF TRICUSPID VALVE AND ASSESSMENT OF RIGHT VENTRICULAR FUNCTIONS Dr.Gökhan Kahveci
Mar 31, 2015
PREOPERATIVE ECHOCARDIOGRAPHIC CLUES FOR THE REPAIR
OF TRICUSPID VALVE AND ASSESSMENT OF RIGHT
VENTRICULAR FUNCTIONS
Dr.Gökhan Kahveci
Secondary Tricuspid Regurgitation
Functional or secondary tricuspid regurgitation (STR) is the most frequent etiology of tricuspid valve pathology
Don’t Touch
Aggressive surgical approach
Secondary Tricuspid Regurgitation
Functional or secondary tricuspid regurgitation (STR) refers to tricuspid regurgitation (TR) occurring secondary to left-sided heart disease or pulmonary hypertension in the absence of organic lesions of the tricuspid valve (TV) apparatus
Secondary Tricuspid Regurgitation
TR would disappear once the primary LHD had been treated???
still influences surgical practice today
TV repair remains an all too infrequentprocedure at most surgical centers
Taramasso M-JACC-2012
STR-Prognosis
Kwak JJ ,AHJ-2008
TV Anatomy
Tricuspid orifice is larger (6-7 cm² andmore triangular (according to mitral ann.)
Tricuspidannulus has an elliptic, nonplanar shape.
Pathophysiology ofSecondary Tricuspid Regurgitation
Most common etiology of STR:RV dilation and dysfunction from LHD The pathophysiology of STR may be
divided into 3 phases:1. Dilation of the right ventricle results in
TA dilation2. Progressive RV and TA dilation, failure of
leaflet coaptation, and significant STR 3. Progressive RV distortion and
eccentricity, tethering of the leaflets
Secondary Tricuspid Regurgitation Significant tricuspid annular dilatation is defined by a diastolic diameter ≥40 mm or ≥21 mm/m² in the four-chamber transthoracic view.
Significant tethering coaptation distance >8
mm ESC 2012 VHD-Guidelines
The prevalence of STR
Degenerative mitral regurgitation 30% of patients have TR ≥2+ at the time of mitral surgery
Rheumatic mitral stenosis 30% of patients have TR ≥2+
ischemic mitral regurgitation 30% of patients have TR
Late TR
Significant TR occurring late after left-heart surgery is observed in up to 40% of patients, with a median survival of 5 years.
TV annuloplasty during mitral surgery results in a lower incidence of late TR.
TR-Echocardiography
2D Echo has the inherent limitation of not being able to show all three tricuspid leaflets together in the same view
Realtime 3D Echo (RT-3DE) has the unique capability of obtaining a short-axis plane of the TV
TR Quantification-EACI 2013
Normal tricuspid valve annulus diameter in adults is 28+5 mm in the four-chamber view (in diastole)
Average TA circumference is 78 ± 7 mm/m²
Significant tricuspid annular dilatation is defined by a diastolic diameter of ≥21 mm/m² (>35 mm)
Tenting area >1 cm² is related severe TR
TR Quantification-EACI 2013
Colour Flow Imaging
The colour flow area of the regurgitant jet is not recommended to quantify the severity of TR. Thecolour flow imaging should only be used for diagnosing TR.
TR Quantification-EACI 2013
VC width
≥7 mm defines severe TR.
Poor accuracy of the in
eccentric jets
3D EROA >75 mm² severe TR
(need validation)
TR Quantification-EACI 2013
Flow convergence method (PISA)
EROA ≥40 mm² or RVol of ≥45 mL indicates
severe TR.
Quantitative but have several limitations-underestimates severity by 30%
TR Quantification-EACI 2013
Peak tricuspid inflow E velocity >1 m/s suggests severe TR
The systolic hepatic flow reversal is specific for severe TR. It represents the strongest additional parameter for evaluating the severity of TR.
TR Quantification-EACI 2013
Lancellotti P-EHJ-2013
RT3DE
The ability to visualize all three tricuspid leaflets simultaneously is a major advantage of RT3DE.
In TR patients, the tricuspid annulus tends to dilate in the septal-lateral and posteroseptal-to-anterolateral dimensions, resulting in a more circular and planar shape compared with healthy controls
3D-TEERT-3D TEE data to describe the tricuspid annulus.Eccentric dilation seen in patients with TR. The tricuspid annulus shape is complex, with annular high and low points, and annular area calculation based on linear measurements significantly overestimates 3D planimetered area
Predictors of Unsuccessful TV Repair Preop RV dysfunction Severe TR Severe TV tethering
Tenting area >1.63 cm²
Tenting distance >0.76 cm Higher pulmonary artery pressures Increased LV remodeling Suture annuloplasty (De vega) Larger ring size MV replacement rather than repair Presence of pacemaker leads
Predictors of Late TR After Mitral Repair
Katsi V-ICTS-2012Dreyfus GD-Heart 2009
Tricuspid Anulus >70 mm at the surgical table or of >40 mm or 21 mm/m² at the echo imaging
Echocardiography and Surgical Technique
Ring annuloplasty should be performed in the presence of isolated annular dilatation.
Conversely, when severe annular dilatationand leaflet tethering are present, pericardial patch augmentation of the anterior leaflet or replacement of the TV should be considered.
ESC-2012-VHD
Predicting the evolution of functional TR after surgical treatment of mitral valve disease remains difficult. Pulmonary hypertension,increased RV pressure and dimension, reduced RV function, AF, pacemaker leads, and the severity of tricuspid valve deformation (tricuspid annulus diameter, coaptation height) are important risk factors for persistence or late worsening of TR.
ESC2012-VHD
Ring annuloplasty is key to surgery for TR. Better long-term results are observed with prosthetic rings than with the suture annuloplasty,
The incidence of residual TR being, respectively, 10% vs 20–35% at 5 years.
Indications for Tricuspid Valve Surgery
ESC 2012 VHD-Guidelines
Severe Right Ventricular Dysfunction????
Indications for Tricuspid Valve Surgery
If secondary TR is less than severe, the diameter of the tricuspid annulus rather than the grade of regurgitation (which is highly subjective and variable) should be the criterion to indicate the need for concomitant TV repair at the time of mitral valve (MV) surgery
Assessment of RV Function
The echocardiographic quantitative assessment of right ventricular (RV) function has been difficult owing to the complex RV
anatomy. Identifying an accurate and reliable
echocardiographic parameter for the functional assessment of the RV still remains a challenge
Assessment of RV Function
It has a complex geometry, appearing triangular when viewed from the front, and crescentic when viewed in a transverse section of the heart
Cannot be fitted to simple geometric models
Limitation of 2D
Essential Imaging Windows and Views-1
Essential Imaging Windows and Views-2
Essential Imaging Windows and Views-3
Essential Imaging Windows and Views-4
Essential Imaging Windows and Views-5
Essential Imaging Windows and Views-6
Right Heart Dimensions
ASE 2010
Right Ventricle DimensionsThe sensitivityof right ventricular sizewith angular changeEnsure that theRVis not foreshortened and that the LVoutflow tract is not opened up(avoid the apical 5-chamber view)
RV Dimensions
RV basal dimension <42 mm (RVD1)
RVOT Dimensions
RVOT proximal diameter <33 mmRVOT proximal diameter <27mm
RV Systolic Function-FAC
RV FAC = EDA-ESA/EDAX100
RV FAC <35%
Prognostic value +Correlation with MRI derived EF
RV Systolic Function-2D RVEF
2D RV EF is not recommended, because of the heterogeneity of methods and the numerous geometric assumptions
ASE 2010
RV Systolic Function-3D RVEF
Three-Dimensional Volume Estimation
RV end-diastolic volume <89 mL/m² RV end-systolic volume <45 mL/m²
(10% to 15% lower in women)
The lower reference limit for RV EF is 44%
Excellent correlation with MRI derived EF
RV Systolic Function-3D RVEF
RV MPI
MPI = IVRT+IVCT/ET
TissueDoppler derived MPI
>0.55 RV dysfunction
TAPSETAPSE may not
reflect whole RV systolic function
<16 mm RV dysf.
Correlation with isotropic derived RVEF
Prognostic value in HF
Doppler Tissue Imaging
Cut-off value of 11.5 cm/s for tricuspid ring systolic velocities is able to accurately predict global RV dysfunction (defined as RVEF <45%).
Myocardial Acceleration During Isovolumic Contraction
IVA measured in the basal segment of the RV free wall of > 1.1 m/s2 correlates well with MRI RVEF >45% (90% sensitivity and specificity).
Angle dependent
Load independent
RV Strain and Strain Rate (STE)
Strain Percentage change in myocardial deformation
Strain rate rate of deformation of myocardium over time
Reflect regional and global RV functionsLess load dependent
RV Strain and Strain Rate (STE)
LV eccentricity index (EccIx)
EccIx, defined as the ratio of the LV antero-posterior to septo-lateral diameters in a short-axis view
EccIx >1 at end-diastole volume overload Ecclx>1 at end systole and diastole pressure overload
ASE-Right Heart Evaulation
Examine the right heart using multiple acoustic windows
Report should represent qualitative and quantitative parameters.
RV sizeRA sizeRV systolic function (at least one of
the following): Fractional area change [FAC]TAPSE S`SPAP
ESC 2012-VHD Guidelines
Evaluations of the RV dimensions and function should be conducted, despite existing limitations of current indices of RV function.
TAPSE <15 mmSt <11 cm/sRVED area > 0.20 cm² could be used to identify patients with
RV dysfunction