Tricuspid Regurgitation in Context

Tricuspid Regurgitation in Context

Joaquín Barba Cosials
Laboratorio de Ecocardiografía
Dpto. Cardiología y Cirugia Cardiovascular
Clinica Universidad de Navarra
Pamplona

24/11/2011

viernes 25 de noviembre de 11


What´s the matter ?




1. Assessment ?




1. Assessment ?
2. Low evidence ?




1. Assessment ?
2. Low evidence ?
3. Indication ?




1. Assessment ?
2. Low evidence ?
3. Indication ?
4. Surgical plan ?




1. Assessment ?
2. Low evidence ?
3. Indication ?
4. Surgical plan ?
5. Rigth ventricle ?



60%

The Society of Thoracic Surgeons Database Spring 2010 report


Mitral Regurgitation Assessment

A1
A3
P1 A2
P3
P2

Enriquez- Sarano M New Engl J Med 2005;352:875-883



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os
ogn
Pr

A1
A3
P1 A2
P3
P2




is
os
ogn
Pr
ism
an
ch
Me
A1
A3
P1 A2
P3
P2




is
os
ogn
Pr
ism
an
ch
Me
tion A1
a A3
if ic A2
nt P1
ua P3
Q P2




is
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ogn
Pr
ism
an
ch
Me
tion A1
a iA3n
to
a
if ic liz
aA2
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Loc
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Q P2



Initial Considerations

ØProlongued clinical course
ØSymtoms: culminating reduced cardiac ouput
Ø90% secondary (PAP >55mmHg)
ØEchocardiographic diagnosis
ØMRI is gold standard for RV function
ØAssessment mechanics = subsequent management
ØMove towards more aggressive treatment


Prevalence

Anwar AM Interact Cardiovasc Thorac Surg 2006;5:638-7


TR survival

Flail leaflets Primary TR

Asintomatic patients

HF,AF,CS,Death

J Thoracic Cardiovasc Surg 2004;128:296-302


TR in ischaemic heart disease TR in mitral valve disease

Fleischmann KF Am J Cardiol 1997;80:1266-1272
Sagie A J Am Coll Cardiol 1994;24:696 –702



Thorac Cardiovasc Surg 2006;133:547–57.



•Anatomy

•Aetiology

•Pathophysiology

•Evaluation



•Anatomy

1 •Aetiology

•Pathophysiology

2 •Evaluation



•Anatomy

1 •Aetiology Repair

•Pathophysiology

2 •Evaluation Indication


Anatomy

Postgrad Med J 2009 85: 546-551


Anatomy

Circulation 2009, 119:2718-2725



Anatomy

A
S
P


Anatomy

Anterior

Posterior

Septal



Tricuspid vs Mitral

•Annulus more circular
more planar
more elastic
•Leaflets 3
no clears
more variable
•More difficult visualization TTE / TEE
•RVF more complex evaluation
•Underestimation

MORE COMPLEX !


Dreyfus GDHeart 2009;95;868-9
Heart 2009;95:931-6


Navia JL Thorac Cardiovasc Surg 2010;139:1473



Risk Factors associated with higher postoperative TR grade

üHigher grade of preoperative TR
üFemale
üLower LVEF
üPreoperative permanent pacemaker
üCoronary artery disease
üLarger LV mass index

Navia JL Thorac Cardiovasc Surg 2010;139:1473



Anomalía de Ebstein


10%

90%


Mechanisms

Mascherbauer J Eur Heart J 2010;31:2841-2843


Geometric Determinants of Functional TR

Circulation 2006, 114:143-149:


Free wall dilatation

Circulation 2006, 114:143-149:


Mechanisms / Evolution

1. R V and annulus dilatation
2. Failure of leaflet coaptation
3. Tethering ?

Heart 2009;95;968-9
Heart 2009;95:931-6


Mechanisms
Right Ventricular Myopathy / Infarction

Right Ventricular Dysfunction / Dilatation

Annular Dilatation Atrial Fibrilation
(+/- leaflet tethering)

Pulmonary
Hypertension

Tricuspid Rheumatic Heart Disease

Regurgitation

Other Primary Valve
Leaflet Injury Disease


Right ventricular morphology

European Journal of Echocardiography (2010) 11, 81–96

Right ventricular morphology
Determinants of severity
a/b= sphericity index c/d= eccentricity index

Kim HK Am J Cardiol 2006;98:236–242


Mechanism of tricuspid regurgitation according to Carpentier

European Journal of Echocardiography 2010;11:307–332



Carcinoid



MRI


Permanent Pacemaker


(41)

J Am Coll Cardiol 2005;45:1672–5)


Evaluation

Eur J Echocardiogr 2009;10: 477–484

real-time three-dimensional echocardiography

Eur J Echocardiogr 2009;10: 477–484


Jet analysis

Central Eccentric



Semi-quantitative assessment

1. flow convergence zone

2. vena contracta

3. jet turbulence area



Quantitative assessment





J Am Soc Echocardiogr 16:777-802, 2003


Annular Dilatation

40mm

Dreyfus GD Ann Thorac Surg 2005;79:127–32

Annular dilatation and Regurgitant Volume

J Thorac Cardiovasc Surg 117: 463-471, 1999


Annular dilatation (>40mm)

Vab de Veire NR J Thorac Cardiovasc Surg 2011;141:1431


Annular dilatation (>40mm)

Grade 3-4 TR Grade 3-4 TR or annulus > 40 mm

prevents right ventricular dilatation
Vab de Veire NR J Thorac Cardiovasc Surg 2011;141:1431


Systolic annular dilatation

J Thorac Cardiovasc Surg 2011;142:308-13


Coaptation height
Annulus

4,7 2,6

Semin Thoracic Surg 22:200.e1-200.e22



Echocardiographic approach

Tethering distance Tethering area

>8mm >16cm2

J Thorac Cardiovasc Surg 2010;139:1483-7)

Progression of Isolated Tricuspid Regurgitation
Late After Left-Sided Valve Surgery

Circulation Journaldoi: 10.1253/circj.CJ-11-0718


RV function TAPSE



RV function


Current questions

•Can real-time 3D echocardiography or CMR provide more
accurate estimation of annular size and therefore predict
late TR after left-sided valvular surgery?

•Can the new imaging modalities help plan surgery and
improve outcomes?

•Can new imaging techniques more accurately assess right
ventricular function, a key determinant of outcome with late
TR?

•Should we monitor patients for potential TR progression? if so
which patients?


Management

Is patient undergoing
Mitral valve surgery ?
Yes No

Is the TR severe? Is the TR severe?

Yes No Yes No

Surgery Consider Surgery if Not for
Symtoms ? Surgical
•Annular dilatation
•Pulmonary Hypertension repair
•TR moderate
Yes No

Surgery Surgery not recomended
Unless severe Unless progresive
RV dysfunction RV dysfunction

ESC/ACC/AHA guidelines


Management

Is patient undergoing
Mitral valve surgery ?
Yes No

Is the TR severe? Is the TR severe?

Yes No Yes No

Surgery Consider Surgery if Not for
Symtoms ? Surgical
•Annular dilatation
repair

?
•Pulmonary Hypertension
•TR moderate
Yes No

Surgery Surgery not recomended
Unless severe Unless progresive
RV dysfunction RV dysfunction

ESC/ACC/AHA guidelines


Functional Regurgitation
Clinical evaluation
Echocardiography
Symptomatic Asymptomatic

Severe Moderate Mild

Normal MV, PASP<60mmHg
MV disease, PASP>60mmHg TAD<40mm or 21mm/m2
TAD>40mm or 21mm/m2

Tethering (+) Tethering (-) Intraoperative TAD > 70mm

TVR or TA + leaflet augmentation Tricuspid repair Re-evaluation / 6 months

Semin Thoracic Surg 2010;22:79-83


Tricuspid valve procedures

10-15 %
N

The Society of Thoracic Surgeons Database Spring 2008 report



a ch
pro
A p
us
eo
tan
cu
P er


J Am Coll Cardiol 2011;58:117–22


Percutaneous approach

J Am Coll Cardiol 2011;58:117–22


European Heart Journal (2011) 32, 1207–1213



Lauten A European Heart Journal 2010: 31, 1274–1281



To take home

•More than mild TR should provoke a detailed assement

•Significant TR lead significant functional impairement
and reduced survival

•Majority TR are secondary to PH or RV disease

•ECHO and MRI to asses aetiology , severity and RV function

•If PM is needed, LV estimulation should be considered



To take home

•In secondary TR undergoing left-sided valvular heart surgery :
surgery Influenced not only by the severity but also annular
dilatation

•Surgery in primary severe symptomatic TR and in those
without symptoms in early failing of RV

•In selected cases, patients with prior TV surgery may
be candidates for percutaneous TV implantation


Tricuspid Regurgitation in Context

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