Understanding right ventricular dysfunction and functional tricuspid regurgitation accompanying mitral valve disease Lina Maria Vargas Abello, MD, Allan.

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Understanding right ventricular dysfunction and functional tricuspid regurgitation accompanying mitral valve disease Lina Maria Vargas Abello, MD, Allan L. Klein, MD, Thomas H. Marwick, MD, PhD, Edward R. Nowicki, MD, MS, Jeevanantham Rajeswaran, MSc, Sarinya Puwanant, MD, FASE, Eugene H. Blackstone, MD, Gösta B. Pettersson, MD, PhD The Journal of Thoracic and Cardiovascular Surgery Volume 145, Issue 5, Pages 1234-1241.e5 (May 2013) DOI: 10.1016/j.jtcvs.2012.01.088 Copyright © 2013 The American Association for Thoracic Surgery Terms and Conditions

Figure 1 TR and RV function. A, Cumulative distribution of TAPSE. Vertical dashed lines represent 95% confidence limits for patients without TR. Arrows point to median value for each TR grade. B, Box and whiskers plot of TAPSE and TR grade. Whiskers represent extreme values, boxes represent the 15th and 85th percentile of values, + sign represents the mean, and horizontal bar represents the median values. C, Cumulative distribution of MPI. Format is as in A. D, Box and whiskers plot of MPI and TR grade. Format is as in B. TR, Tricuspid regurgitation; RV, right ventricular. The Journal of Thoracic and Cardiovascular Surgery 2013 145, 1234-1241.e5DOI: (10.1016/j.jtcvs.2012.01.088) Copyright © 2013 The American Association for Thoracic Surgery Terms and Conditions

Figure E1 Consolidated Standards of Reporting Trials–type diagram showing study design and patient population. TR, Tricuspid regurgitation. The Journal of Thoracic and Cardiovascular Surgery 2013 145, 1234-1241.e5DOI: (10.1016/j.jtcvs.2012.01.088) Copyright © 2013 The American Association for Thoracic Surgery Terms and Conditions

Figure E2 Transthoracic echocardiographic assessment of right-sided heart morphology using the apical 4-chamber view. A, RA systolic area shaded. B, RV base-to-apex length. C, TV tethering distance in systole. D, TV tethering area in systole (shaded). RV, Right ventricle; LV, left ventricle; RA, right atrium; LA, left atrium. The Journal of Thoracic and Cardiovascular Surgery 2013 145, 1234-1241.e5DOI: (10.1016/j.jtcvs.2012.01.088) Copyright © 2013 The American Association for Thoracic Surgery Terms and Conditions

Figure E3 Transthoracic echocardiographic assessment of RV function: TAPSE. A, Annulus plane at end diastole (dotted line). B, TAPSE is measured at end systole. Arrow shows movement of tricuspid annular plane from end diastole to end systole. RV, Right ventricular. The Journal of Thoracic and Cardiovascular Surgery 2013 145, 1234-1241.e5DOI: (10.1016/j.jtcvs.2012.01.088) Copyright © 2013 The American Association for Thoracic Surgery Terms and Conditions

Figure E4 Transthoracic echocardiographic assessment of RV function: MPI. Schematic representation of Doppler intervals for calculating MPI. MPI = (C+R)/E, calculated by measuring the interval between cessation and onset of flow across TV and pulmonary valve ejection time. C, Isovolumetric contraction time; R, isovolumetric relaxation time; E, pulmonary ejection time; TV, tricuspid valve; PV, pulmonary valve. The Journal of Thoracic and Cardiovascular Surgery 2013 145, 1234-1241.e5DOI: (10.1016/j.jtcvs.2012.01.088) Copyright © 2013 The American Association for Thoracic Surgery Terms and Conditions

Figure E5 TV annular shortening. TV plane in diastole is shown as a and in systole as b. RV, Right ventricle. The Journal of Thoracic and Cardiovascular Surgery 2013 145, 1234-1241.e5DOI: (10.1016/j.jtcvs.2012.01.088) Copyright © 2013 The American Association for Thoracic Surgery Terms and Conditions

Figure E6 Box and whiskers plot of RVSP and TR grade. Whiskers represent extreme values, boxes represent the 15th and 85th percentile of values, + sign represents the mean, and horizontal bar represents the median values. RVSP, Right ventricular systolic pressure; TR, tricuspid regurgitation. The Journal of Thoracic and Cardiovascular Surgery 2013 145, 1234-1241.e5DOI: (10.1016/j.jtcvs.2012.01.088) Copyright © 2013 The American Association for Thoracic Surgery Terms and Conditions

Figure E7 Bubble plots of qualitative clinical assessment of right-sided heart morphology and function associated with TR grade. Area of bubble corresponds to number of observations. A, RA dilatation grade. B, RV dilatation grade. C, RV dysfunction grade. TR, Tricuspid regurgitation. The Journal of Thoracic and Cardiovascular Surgery 2013 145, 1234-1241.e5DOI: (10.1016/j.jtcvs.2012.01.088) Copyright © 2013 The American Association for Thoracic Surgery Terms and Conditions

Figure E8 Box and whiskers plots of right-sided heart morphology and TR grade. Format is as in Figure E6. A, RA systolic area. B, TV tethering distance. RA, Right atrial; TR, tricuspid regurgitation. The Journal of Thoracic and Cardiovascular Surgery 2013 145, 1234-1241.e5DOI: (10.1016/j.jtcvs.2012.01.088) Copyright © 2013 The American Association for Thoracic Surgery Terms and Conditions

Figure E9 MPI and right-sided heart morphology. A, Scattergram of MPI and RA systolic area. Loess smoother shown as solid lines. B, Scattergram of MPI and TV tethering distance. RA, Right atrial; TV, tricuspid valve. The Journal of Thoracic and Cardiovascular Surgery 2013 145, 1234-1241.e5DOI: (10.1016/j.jtcvs.2012.01.088) Copyright © 2013 The American Association for Thoracic Surgery Terms and Conditions

Figure E10 Scattergram of TAPSE and MPI. Loess smoother shown as solid lines. TV, Tricuspid valve. The Journal of Thoracic and Cardiovascular Surgery 2013 145, 1234-1241.e5DOI: (10.1016/j.jtcvs.2012.01.088) Copyright © 2013 The American Association for Thoracic Surgery Terms and Conditions

Figure E11 Three-dimensional perspective graph of TR grade, MPI, and TAPSE. TR, Tricuspid regurgitation; MPI, myocardial performance index; TAPSE, tricuspid annular plane systolic excursion. The Journal of Thoracic and Cardiovascular Surgery 2013 145, 1234-1241.e5DOI: (10.1016/j.jtcvs.2012.01.088) Copyright © 2013 The American Association for Thoracic Surgery Terms and Conditions

Figure E12 Nomogram based on multivariable equation (analysis 2 in Table 4) relating percentage of patients in TR grades 3+/4+ to right-sided heart morphology. A, RA systolic area. B, Tethering distance. TR, Tricuspid regurgitation; RA, right atrial. The Journal of Thoracic and Cardiovascular Surgery 2013 145, 1234-1241.e5DOI: (10.1016/j.jtcvs.2012.01.088) Copyright © 2013 The American Association for Thoracic Surgery Terms and Conditions