Advances in Tricuspid Regurgitation Congress of the European Society of Cardiology (ESC) Munich, August 25-29, 2012 Assessing the Impact on the Right Ventricle Stephan Rosenkranz, MD Clinic III for Internal Medicine (Cardiology) and Center for Molecular Medicine Cologne (CMMC) Heart Center at the University of Cologne, DE stephan.rosenkranz@uk-koeln.de
Conflict of Interest - Disclosure Within the past 12 months, I or my spouse/partner have had a financial interest/arrangement or affiliation with the organization(s) listed below. Affiliation/Financial Relationships Honoraria for lectures / Consulting / Advisory Board Acitivies / Participation in Clinical Trials: Actelion, AstraZeneca, BayerS, Gilead, GSK, Lilly, Novartis, Pfizer, United Therapeutics Research funding: Actelion, Baye, Novartis, Pfizer Financial shares and options: None.
Cardio-Pulmonary Interaction Postcapillary PH Left Heart Disease LVEDP, PCP Precapillary PH Intrinsic TR PAP Right Heart Failure Cor pulmonale Death RV Afterload
Age-Associated Increases in Pulmonary Artery Systolic Pressure in the General Population Lam CS et al., Circulation 2009; 119: 2663-2670
Cardio-Pulmonary Interaction Postcapillary PH Left Heart Disease LVEDP, PCP Precapillary PH Intrinsic TR PAP Right Heart Failure Cor pulmonale Death RV Afterload
Cardio-Pulmonary Interaction PAH COPD Fibrosis CTEPH Postcapillary PH Left Heart Disease LVEDP, PCP Intrinsic TR Precapillary PH PAP Right Heart Failure Cor pulmonale Death RV Afterload
Cardio-Pulmonary Interaction PAH COPD Fibrosis CTEPH Postcapillary PH Left Heart Disease LVEDP, PCP HFpEF HFrEF Valve disease Precapillary PH PAP Right Heart Failure Cor pulmonale Death Intrinsic TR RV Afterload
Pathology of RV Dimensions, Geometry, and Function RV pressure overload Pulmonary embolism Pulmonary valve stenoses Pulmonary hypertension Systemic right ventricle RV volume overload Atrial septal defect Pulmonary regurgitation Tricuspid regurgitation (TR) Anomalous pulmonary veins Myocardial diseases Functional TR - congenital Arrhythmogenic right ventricular dysplasia Chronic left sided heart failure - Intrinsic valve disease: - acquired
TR and the Right Ventricle Intrinsic Tricuspid Regurgitation Acquired: Endocarditis, Traumatic flail leaflet Impingement of pacer leads on TV closure Congenital: Ebstein s anomaly others Surgical risk: - acute - long-term Natural course: - Progressive RV dilatation/dysfunction - liver congestion, anemia, etc. Chronic RV volume overload
Pathophysiological Relevance of RV Dysfunction RV almost dispensable for cardiac function with normal PVR Starr I et al, Am Heart J 1943; 26: 291-301
TR and the Right Ventricle Intrinsic Tricuspid Regurgitation Acquired: Endocarditis, Traumatic flail leaflet Impingement of pacer leads on TV closure Congenital: Ebstein s anomaly others Surgical risk: - acute - long-term Natural course: - Progressive RV dilatation/dysfunction - liver congestion, anemia, etc. Chronic RV volume overload Survival rates in TR at 1 year: (5223 patients, mean age 67 yrs) - no TR 92% - mild 90% - moderate 79% - severe 64% Nath et al., J Am Coll Cardiol 2004; 43: 405
Volume overload of the RV in severe TR
Cardio-Pulmonary Interaction PAH COPD Fibrosis CTEPH Postcapillary PH Left Heart Disease LVEDP, PCP HFpEF HFrEF Valve disease Precapillary PH PAP Right Heart Failure Cor pulmonale Death Intrinsic TR RV Afterload
Echocardiographic Assessment of the Right Heart RV Pressure Overload (Pulmonary Arterial Hypertension RV Volume Overload (Isolated TR) Haddad et al. Circulation 2008; 117: 1717-1731 Rudski et al., J Am Soc Echocardiogr 2010; 23: 685-713
Echocardiographic Assessment of the Right Heart RV Pressure Overload (Pulmonary Arterial Hypertension RV Volume Overload (Isolated TR) RV does not tolerate pressure overload well Acute pressure overload: RV dilatation and failure Chronic pressure overload: RV hypertrophy (and failure) IVS moved towards the LV Haddad et al. Circulation 2008; 117: 1717-1731 Rudski et al., J Am Soc Echocardiogr 2010; 23: 685-713
Echocardiographic Assessment of the Right Heart RV Pressure Overload (Pulmonary Arterial Hypertension RV Volume Overload (Isolated TR) Volume overload RV dilatation Paradoxical septal movement RV tolerates volume overload for a long time without a decrease in RV systolic function However, a longstanding volume overload is related to an increased morbidity and mortality Haddad et al. Circulation 2008; 117: 1717-1731 Rudski et al., J Am Soc Echocardiogr 2010; 23: 685-713
Echocardiographic Assessment of the Right Heart Rudski et al., J Am Soc Echocardiogr 2010; 23: 685-713
Hemodynamic Variables: Systolic PA- Pressure CW-Doppler: Measurement of PASP TV-Velocity dp = 4 x v 2 max Transtricuspid Pressure Gradient + RAP Systolic PA Pressure Highest sensitivity and specifity of all non-invasive tools
Pulmonary Hemodynamics in Left Heart Disease Impact of Volume Load 70 year-old patient 70 year-old patient Diastolic Heart Failure 6 days later Body weight 80 kg Body weight now 73 kg PAPm mmhg 60 50 40 30 20 10 PAPm PCWP TPG mmhg PCWP TPG PAPm 51 mmhg 21 30 60 50 40 30 20 10 PAPm 24 mmhg 11 13
Echocardiography of the Right Heart Guidelines of the Amercian Society of Echocardiography / European Association of Echocardiography Lange Achse Kurze Achse RAD RAD Rudski et al., J Am Soc Echocardiogr 2010; 23: 685-713
Echocardiography of the Right Heart Guidelines of the Amercian Society of Echocardiography / European Association of Echocardiography Kurze Achse Rudski et al., J Am Soc Echocardiogr 2010; 23: 685-713
Echocardiography of the Right Heart Measurement of RA Dimensions Normal value: < 18 cm 2 RA area is prognostically relevant in TR and PAH Rudski et al., J Am Soc Echocardiogr 2010; 23: 685 Raymond et al. J Am Coll Cardiol 2002; 39: 1214 Bustamante et al. J Am Soc Echocardiogr 2002; 15: 1160
TAPSE Tricuspid Annular Plane Systolic Excursion RV RA Normal value: 21,7 ± 4,7 mm Pathological < 15 mm Emilsson K Clin Physiol Funct Imaging 2004; 24: 212 215
TAPSE Tricuspid Annular Plane Systolic Excursion Prognostic Impact Forfia PR et al Am J Respir Crit Care Med 2006
Echocardiography: RV Function RV Fractional Area Change (FAC) FAC = 100 x Area ED Area ES Area ED Rudski et al., J Am Soc Echocardiogr 2010; 23: 685-713
Coupling of PVR and RVEF Survival (%) PVR Survival (%) RVEF Survival (%) Survival in PAH Stratified by PVR and RVEF 100 80 PVR <650 100 80 RVEF >35 60 PVR >650 60 40 40 RVEF <35 20 20 p=0.04 p<0.001 0 0 25 50 Time (months) 75 100 125 0 0 25 50 Time (months) 75 100 125 100 80 60 40 RVEF >35, PVR <650 (n=36) RVEF >35, PVR >650 (n=20) RVEF <35, PVR >650 (n=41) RVEF <35, PVR <650 (n=13) 20 0 0 25 50 Time (months) 75 100 125 van de Veerdonk et al. J Am Coll Cardiol 2011; 58: 2511-2519
Structured Investigation of Right Heart Based on: Rudski et al., J Am Soc Echocardiogr 2010; 23: 685-713
Independent determinants of clinical outcome in Patients undergoing surgery for isolated TR - RV end-systolic area (RV-ESA) 20 cm 2 - Anemia (hemoglobin 11.3 g/dl) Kim YJ et al., Circulation 2009; 120: 1672-1678
Independent determinants of clinical outcome in Patients undergoing surgery for isolated TR Right index of myocardial performance ratio (RIMP) Topilsky Y et al., Circulation 2011; 123: 1929-1939
Independent determinants of clinical outcome in Patients undergoing surgery for isolated TR RV Function: Right index of myocardial performance ratio (RIMP) Topilsky Y et al., Circulation 2011; 123: 1929-1939
Clinical and Echocardiographic Outcomes after Surgery for severe isolated TR Multivariate Cox-regression analysis for event-free survival Kim JB et al., J Thorac Cardiovasc Surg 2012 (in press)
Volume overload and RV Function: cmri
Volume overload and RV Function: cmri cmri is the reference method for assessment of RV volumes and EF Analysis is based on the method of disc summation
Volume overload and RV Function: cmri Limitations: Limited availability High costs Time-consuming acquisition and analysis No solid data on cmri Variables in TR Bleeker et al. Heart 2006;92 Suppl 1:i19-26 Babu-Narayan et al. J Cardiovasc Med 2007;8:23-29
RV Volume and Function: 2D, 3D echo, cmri Van der Zwaan et al. Eur J Echocardiogr. 2011
RV Remodeling determines TV Geometry and the Severity of Functional TR: 3D Echo Conclusion: Functional TR severity is determined by septal-lateral annulus and RV dilation, and tenting of septal and anterior leaflets. TV leaflet tenting is mainly determined by septallateral RV inlet dilation, and tricuspid annulus dilation is closely linked with inlet RV dilation. Song JM et al., Korean Circ J 2010; 40: 448-453
Take home TR may be functional (increased RV afterload) or result from intrinsic TV disease Important to detect (and treat) cause of functional TR Pressure overload poorly tolerated by RV Chronic volume overload of RV is detrimental and is associated with poor prognosis RV end-systolic dimensions and RV Function are independent predictors of outcome after TVR cmri: reference method for RVEF, but no data on TR 3D echo: function and geometry
Take home TR may be functional (increased RV afterload) or result from intrinsic TV disease Important to detect (and treat) cause of functional TR Pressure overload poorly tolerated by RV Chronic volume overload of RV is detrimental and is associated with poor prognosis RV end-systolic dimensions and RV Function are independent predictors of outcome after TVR cmri: reference method for RVEF, but no data on TR 3D echo Timely repair may be advised in patients with severe, isolated TR, before the development of significant RV dilatation and dysfunction