Prof. JL Zamorano Hospital Universitario Ramón y Cajal
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1 Prof. JL Zamorano Hospital Universitario Ramón y Cajal
2 Should we forget TR? Nath J et al. Impact of tricuspid regurgitation on long-term survival. J Am Coll Cardiol. 2004; 43:
3 Why is it difficult to quantify TR? The tricuspid valve is often neglected It has a complex & variable anatomy TR is load dependent No gold standard (invasive quantification has many limitations) Lack of outcome studies relating to TR quantification
4 ETIOLOGY Functional TR The most common No structural lesion RV pressure overload Primary TR RV volume overload Prolapse Organic TR Carcinoid TV
5 2D Echo signs of TR severity RA, RV & IVC dilatation Paradoxical septal motion TV anatomy TV annulus
6 Color flow Doppler Mild moderate severe JA: <5cm 2 5cm 2-10cm 2 >10cm 2 JA/RAA: <20% 20%-40% >40%
7 Limitations of color flow Doppler Central Vs. eccentric jets Gain settings & aliasing velocity Loading conditions JA/RAA: RA enlargement with severe TR Considered less accurate then other quantitative methods (VC, PISA) Still
8 TR severity by CW Doppler Mild Moderate Severe
9 TR Jet CW Doppler - A full CW Doppler envelope indicates more severe TR than a faint signal - A triangular CW contour with an early peak velocity indicates elevated RA pressure or prominent pressure wave in the RA due to severe TR - The velocity of TR does not reflect the severity of TR - Massive TR: often associated with a low jet velocity = near egalization of RA and RV pressure - Mild TR + severe pulmonary hypertension : possible high velocity jet - SOME TIPS
10 Tricuspid E-wave peak velocity (n=118) E >65 cm/sec identified severe TR sensitivity=73% specificity=88% Danicek et al, AJC 2006
11 Hepatic veins systolic flow reversal severe TR Correlation with clinical TR: PPV=91% NPV=78% moderate TR Shapira et al, JASE 1998
12 Vena Contracta Apical 4CV or parasternal RV inflow view Optimize gain settings High aliasing velocity High frame rate Zoom in, mid systole Observe all 3 components of the regurgitant flow
13 Vena Contracta Mild TR: VC<0.3? Moderate TR: 0.3? <VC<7mm Severe TR: VC>7mm VC=4.5mm VC=12mm
14 Vena Contracta Vs. PISA EROA (n=71) Tribouilloy et al, JACC 2000
15 Vena Contracta Vs. Hepatic Flow Reversal Tribouilloy et al, JACC 2000
16 Limitations of Vena Contracta Small measurements (each pixel makes a difference ) Overlap in values for small/moderate/severe TR Non circular When there is more than one TR jet Is it really better than color jet area? (outcome studies?)
17 Severity TR
18 Echocardiography for evaluation of TR severity Recommendtaions for Evaluation of the Severiy of Native Valvular Regurgitation with Two-dimensional and Doppler Echocardiography
19 Non Circular Vena Contracta RA RV 1.6 cm RV 0.65 cm RA 3D VENA CONTRACTA
20 Practical Estimation of TR by PISA At V nq = 28 cm/sec: Mild TR: r < 0.5 cm Moderate TR: 0.6 cm < r < 0.9 cm Severe TR: r > 0.9 cm
21 Problems with PISA Localizing the regurgitant orifice Irregular rhythms Biological variability
22 Echocardiographic detection of clinical TR Sensitivity Specificity Jet area 9cm 2 92% 71% JA/RAA 37% 66% 61% VC 8mm 71% 71% HV systolic flow reversal 82% 89% Shapira et al, JASE 1998
23 Severe TR both cases. Is it the same?
24 New classification Hahn R, Zamorano JL. Eur Heart J Cardiovasc Imaging Dec 1;18(12):
25 No doubt. Is not the same
26 Mortality rate at 1 year
27 Mortality at 1 year Mortality at 1 year all vs Pulm. HT
28 Does it meet specific criteria for mild or severe TR? Mild Probably moderate Severe Apply quantitative methods VC < 3 ERO < 20 Vol < 30 VC 3-7 ERO Vol < 30 VC > 7 ERO > 40 Vol > 45? Mild TR Moderate TR VC > 13 ERO >60 Vol >70 Severe TR no yes Torrential or Massive TR
29 CONCLUSIONS TR severity assessment should be performed in an integrative manner +++ using qualitative and quantitative parameters Vena Contracta Width ++ / EROA (R Vol) ++ Serial assessments of TR are recommended because TR severity can be affected by multiple factors, such as volume status and afterload Severe TR: role of RV shape and function analysis. Severe or Massive / Torrential
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