Assessment of Tricuspid and Pulmonic Valve Disease: Importance of 3D

Transcription

1 ssessment of Tricuspid and ulmonic Valve Disease: Importance of 3D Roberto M Lang, MD nterior eptal M-mode 2D Echocardiography osterior eptal nterior eptal 1

2 THE TV ON 3D ECHO RV perspective R perspective THE TRICUID VLVE: DDED VLUE OF 3D IMGING y y 2D x z 3D x < 5% of pts ~ 85% of pts 2

3 THE NORML TRICUID VLVE COMLEX 1. Three leaflets nterior eptal osterior 2. Fibrous annulus 3. Chordae tendinae 4. apillary muscles 5. R myocardium 6. RV myocardium Courtesy Dr. tephen. anders, rofessor of ediatrics (Cardiology), Harvard Medical chool 3

4 HOW MNY LEFLET DOE THE TRICUID VLVE HVE? 16.6% Typical three-leaflets 16.6% even leaflets (4 accessory leaflets) 36 adult human hearts # leaflets vary from 3-7 Extra leaflets are called accessory leaflets ccessory leaflets are common Lama, et. al. nat ci Int Mar;91(2):

5 MBIGUITY OF LEFLET IMGED ON 2D RV inflow view MBIGUITY OF LEFLET IMGED ON 2D pical 4-chamber view 5

6 Basal X view orta and single leaflet nterior leaflet orta osterior or anterior leaflet nterior or septal leaflet orta and two leaflets nterior leaflet osterior leaflet orta LVOT/septum and two leaflets eptal leaflet LVOT J m oc Echocardiogr 2016;29:74-82.) osterior leaflet nterior leaflet 2D view with septum eptal or posterior leaflet 2D view without septum RVIF view eptal leaflet eptal leaflet osterior leaflet 6

7 ost LVD study RV inflow view RV inflow view 2 resentation Title Here 13 ost LVD study RV inflow view #1 RV inflow view #2 Mild TR evere TR resentation Title Here 14 7

8 J m oc Echocardiogr 2016;29:74-82.) pical view 4 CV nterior or posterior leaflet eptal leaflet nterior leaflet 5-chamber view LVOT Coronary sinus osterior leaflet MECHNIM OF TRICUID REGURGITTION rimary (or Organic ) Intrinsic abnormality of the valve apparatus 15-30%* of TR econdary (or Functional ) TV annular dilatation, RV dilatation and papillary muscle displacement 70-85%* of TR ntunes MJ, Barlow JB, Heart

9 rimary/organic TR M/ICD Device Location 26 year-old with dilated cardiomyopathy on the transplant list RV inflow 4C evere TR 4C ICD inserted and echo performed 8 days later RV inflow RV perspective re- ICD R perspective ost-icd 17 - COMMIURE: CORRECT OITION : ostero-septal ntero-posterior Middle ntero-septal 9

10 rimary (Organic) TR acemaker/icd 89 year-old man with right heart failure ast medical history: CD, MV repair, TVI in 2009 ermanent pacemaker implantation post TVI for bradycardia 10

11 CEMKER DHERENCE 11

12 FUNCTIONL TRICUID REGURGITTION Chronic E, Lung disease RV ischemia, VOL, CM 70-85%* of TR Left-sided valve disease trial fibrillation T dilatation RV enlargement M displacement TV tethering FTR L-R shunt Dreyfus G. J m Coll Cardiol 2015;65: TRICUID VLVE MITRL VLVE Tricuspid valve Mitral valve Different valve orifices Different subvalvular apparatuses Different ventricles Yet TR and MR are assessed in similar ways 12

13 JE 2017 GRDING OF TRICUID REGURGITTION EVERITY 13

14 TRICUID VLVE MITRL VLVE 64 year-old man with a NICM LVEF 20% TR I LOD DEENDENT Functional TR 46 mm Tricuspid annulus dilatation may be a more reliable indicator of TV pathology than degree of regurgitation Good correlation between T diameter and TR regurgitant volume TR varies depending on preload, afterload, RV function resentation Title Here 28 14

15 TRICUID VLVE MITRL VLVE re and post peritoneal dialysis Normal tricuspid annular dimension TRICUID VLVE MITRL VLVE TopilskyY et. al. Circulation 2010;122 TR depends on respiratory phase T = 51 mm T = 55 mm 15

16 Functional TR and annular dilatation The annulus is dilated if it measures 1. > 40 mm or > 21 mm/m 2 on 2D transthoracic echocardiography pical 4-chamber view In diastole 2. > 70 mm on direct intraoperative measurement EC/ECT Guidelines for management of VHD EHJ 2012 CC/H Guidelines for management of VHD JCC 2014 resentation Title Here 31 IMORTNCE OF THE TRICUID NNULU erforming tricuspid annuloplasty based on T dilatation rather than TR degree results in improved surgical outcome Despite a sicker MV +TV repair group MV + TV repair MV repair only 10 years 90.3% 85.5% p=n Grade III-IV TR 1% 34% p<0.001 Class III-IV CHF 0% 14% < 0.01 Dreyfus et al. nn Thorac urg,

17 T size measured by 2D echocardiography should be interpreted with caution because it is underestimated by both 2D TTE and TEE. ROLE FOR 3D ECHOCRDIOGRHY Better approximation of septal-lateral dimension lso allows measurement of antero-posterior dimension ddetia K, Muraru D, Veronisi F, Badano L, Lang RM et. al. work in progress 17

18 On the horizon 3D Echo Traditional 4-chamber dimension Long-axis dimension hort-axis dimension RV focused view dimension oftware-generated annulus ddetia K, Muraru D, Veronisi F, Lang RM, Badano L et. J m Coll Cardiol (in press) TRICUID NNULU addle-shaped High points anteroposterior Low points mediallateral Ellipsoid shape R Ton-Nu Circulation Courtesy F. Veronesi, hd. pex 18

19 FUNCTIONL TRICUID REGURGITTION Dreyfus et al. T 2005 T dilatation occurs mostly along the RV free-wall eptal portion of the tricuspid annulus relatively fixed FUNCTIONL TRICUID REGURGITTION Normal 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 m Coll Cardiol

20 MECHNIM OF TRICUID REGURGITTION 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 pinner EM. Circulation 2011 T dilated if >40 mm in apical 4-chamber view THE CC/H 2014 GUIDELINE EC/ECT Guidelines for management of VHD EHJ 2012 CC/H Guidelines for management of VHD JCC

21 MECHNIM OF TRICUID REGURGITTION Fukuda Circulation 2005 re-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 UC (0.88 and 0.87 respectively) 21

22 MECHNIM OF TRICUID REGURGITTION RV basal dimension RV length Group (N) Controls (99) Id FTR (141) HTN FTR (140) TR None Matched for ERO s Normal <50 mmhg 50 mm Hg ssociations: Controls ging, fib T Normal Tenting Normal Normal RV Base Normal RV Length Normal Normal Remodeling -- Conical Elliptical Topilsky Y, Circ Cardiovasc Imaging. 2012;5: MECHNIM OF TRICUID REGURGITTION TV tenting volume by 3DE (accounting for both enlarged annulus area and leaflet tenting) is the major determinant of residual functional TR after annuloplasty Tenting volume >2.3 cm 3 Min Y et al. Eur Heart J

23 NEW DIRECTION: EVLUTION OF FTR MORE COMREHENIVE ROCH Dreyfus et. al. JCC 2015 ON THE HORIZON Muraru D et. al. European Heart Journal Cardiovascular Imaging 23

24 Thank you! BEWRE THE ULTROUND BEM OFTEN ELICIT FINDING THE HITORY ND HYICL EXM CNNOT 24