3D Echo for Evaluation of Tricuspid Regurgitation Jong-Min Song, MD, PhD Asan Medical Center University of Ulsan College of Medicine Seoul, Korea
Causes of TR Primary causes (25%) Rheumatic Myxomatous Ebstein anomaly Endomyocardial fibrosis Endocarditis Carcinoid disease Traumatic (blunt chest injury, laceration) Iatrogenic (pacemaker/defibrillator lead, RV biopsy) Secondary causes (75%) Left heart disease (LV dysfunction or valve disease) resulting in pulmonary hypertension Any cause of pulmonary hypertension (chronic lung disease, pulmonary thromboembolism, left to right shunt) Any cause of RV dysfunction (myocardial disease, RV ischemia/infarction) Circulation. 2009;119:2718-2725
Functional TR Often accompanies various left-side valvular heart and myocardial diseases. Associated with worse survival Nath J, J Am Coll Cardiol 2004;43;405-9.
Pathogenesis of FTR Geometric Alteration of TV Annulus dilation Dreyfus GD. Ann Thorac Surg. 2005;79:127-132. Colombo T. Cardiovasc Surg. 2001;9:369-77. Mikami T. Am J Cardiol 1984;53:160-3. Ubago JL. Am J Cardiol. 1983;52:155-8. Leaflet tethering/tenting Fukuda S. Circulation. 2005;111:975-979. Sugimoto T. J Thorac Cardiovasc Surg. 1999;117:463-71. Sagie A. Doppler color flow study. J Am Coll Cardiol. 1994;24:446-53.
Annulus Dilation Dreyfus GD, Ann Thorac Surg. 2005;79:127-132
Tricuspid Annulus Fukuda S, Circulation. 2006;114(suppl):I-492 I-498
Geometric Determinants of FTR Ton-Nu T et al. Circulation. 2006;114:143-9
Geometric Determinants of FTR Ton-Nu T et al. Circulation. 2006;114:143-9
Geometric Determinants of FTR Ton-Nu T et al. Circulation. 2006;114:143-9
Geometric Determinants of FTR Ton-Nu T et al. Circulation. 2006;114:143-9
Dynamic Change of Annulus Miglioranza MH, JASE 2015;28:226-35
Tricuspid Leaflets on 2D Echo Feigenbaum s Echocardiography
Tricuspid Leaflets on 2D Echo Badano LP, Eur J Echocardiogr 2009;10:477 84
Tricuspid Valve
3D Echo for Tricuspid Valve
Tricuspid Leaflets on 2D Echo Addetia K et al, JASE 2016;29:74-82
Tricuspid Leaflets on 2D Echo Hahn RT, Circ Cardiovasc Imaging.2016;9:e005332
Tricuspid Leaflets on 2D Echo Addetia K et al, JASE 2016;29:74-82
Tricuspid Leaflets on 2D Echo Hahn RT, Circ Cardiovasc Imaging.2016;9:e005332
Tricuspid Leaflets on 2D Echo Addetia K et al, JASE 2016;29:74-82
Tricuspid Leaflets on 2D Echo Hahn RT, Circ Cardiovasc Imaging.2016;9:e005332
3D Echo for TV
Geometric Determinants of FTR 54 patients with various degrees of functional tricuspid regurgitation P A S P A S P A S A P S A S P S-L plane A-P plane Park YH et al. IJC 2008;124:160-5
Leaflet Tethering/Tenting Fukuda S, Circulation. 2005;111:975-979
Angle ( ) Geometric Determinants of FTR 2D color A P S 40 Sα Pα Mild 30 Aα * 20 * Moderate * 10 Severe 0 Mild Moderate Severe (N=11) (N=32) (N=11) * p<0.05, p<0.005 vs. Aα Park YH et al. IJC 2008;124:160-5
Distal Jet Area / RA Area Geometric Determinants of FTR Variables r Univariate P Multivariate P Aα 0.48 < 0.001 0.31 Pα 0.31 < 0.05 0.58 Sα 0.46 < 0.001 < 0.005 Septal-lateral (S-L) annulus diameter 0.47 < 0.001 < 0.01 Antero-posterior annulus diameter 0.46 < 0.001 0.58 Tricuspid tenting volume 0.49 < 0.001 0.30 Pulmonary artery systolic pressure (PASP) 0.36 < 0.01 < 0.05 1.00 0.75 Y=0.009X+0.20 R=0.46 P<0.001 N=54 1.00 0.75 Y=0.18X-0.28 R=0.47 P<0.001 N=54 1.00 0.75 Y=0.006X+0.11 R=0.36 P<0.01 N=54 0.50 0.50 0.50 0.25 0.25 0.25 0.00 0 20 40 60 0.00 0 0.00 2 3 4 5 0 20 40 60 80 Sα ( ) S-L diameter (cm) PASP (mm Hg)
Residual TR after TAP Although significant FTR is usually surgically managed using tricuspid annuloplasty (TAP), some studies reported persistence of FTR in nearly 50% of patients following TAP. Matsunaga A, Circulation. 2005;112:I453-457
Predictors of Residual TR after TAP Fukuda S, Circulation. 2005;111:975-979
Geometric Change After TAP A P S S-L A-P Min SY, Eur Heart J. 2010:31; 2871 2880
Predictors of Severe TR After TAP Min SY, Eur Heart J. 2010:31; 2871 2880
Vena Contracta in FTR Sugeng L, JASE 2007;20:1050-1057
Short-axis plane Vena Contracta Widths A Septal-lateral plane Antero-posterior plane B Song JM, JASE 2011;24:663-70
Measurements by RT3DE A B Anterior Posterior Septal Song JM, JASE 2011;24:663-70
Vena Contracta Width (cm) Vena Contracta Area (cm 2 ) EROA & Vena Contracta r=0.761 p<0.001 r=0.808 p<0.001 r=0.782 p<0.001 S-L VC A-P VC EROA (cm 2 ) A-P VC S-L VC: 0.39 0.37 cm, p<0.001 EROA (cm 2 ) Song JM, JASE 2011;24:663-70
Tricuspid Valve Circulation. 2009;119:2718-2725 Circulation. 1971;43:333-48
Quantification of TR JASE 2003;16:777-802
Stage of TR 2014 AHA/ACC Guideline
3D Vena Contracta Moderate TR Severe TR A-P VC: 0.76 cm Sensitivity 100% Specificity 66% VC Area: 0.37 cm 2 Sensitivity 100% Specificity 69% VC Area: 0.57 cm 2 Sensitivity 100% Specificity 64% A-P VC: 1.26 cm Sensitivity 88% Specificity 80% S-L VC: 0.63 cm Sensitivity 82% Specificity 83% S-L VC A-P VC VC Area S-L VC: 0.84 cm Sensitivity 75% Specificity 91% S-L VC A-P VC VC Area Song JM, JASE 2011;24:663-70
Organic TR
Transcatheter Intervention for TR Trialign TM system (Mitralign Inc.) Hahn RT, Circ Cardiovasc Imaging.2016;9:e005332
Transcatheter Intervention for TR Forma Spacer (Edwards Lifesciences) Hahn RT, Circ Cardiovasc Imaging.2016;9:e005332
Summary 3D echo is useful in patients with TR Annulus dilatation Leaflet tethering & tenting Predicting residual TR after TAP Evaluating severity of TR Primary cause of TR Guiding interventional treatment of TR