PREOPERATIVE ECHOCARDIOGRAPHIC CLUES FOR THE REPAIR OF TRICUSPID VALVE AND ASSESSMENT OF RIGHT VENTRICULAR FUNCTIONS Dr.Gökhan Kahveci

Secondary Tricuspid Regurgitation  Functional or secondary tricuspid regurgitation (STR) is the most frequent etiology of tricuspid valve pathology Don’t Touch Aggressive surgical approach

Secondary Tricuspid Regurgitation  Functional or secondary tricuspid regurgitation (STR) refers to tricuspid regurgitation (TR) occurring secondary to left-sided heart disease or pulmonary hypertension in the absence of organic lesions of the tricuspid valve (TV) apparatus

Secondary Tricuspid Regurgitation TR would disappear once the primary LHD had been treated??? still influences surgical practice today TV repair remains an all too infrequent procedure at most surgical centers Taramasso M-JACC-2012

STR-Prognosis Kwak JJ,AHJ-2008

TV Anatomy Tricuspid orifice is larger (6-7 cm² and more triangular (according to mitral ann.) Tricuspid annulus has an elliptic, nonplanar shape.

Pathophysiology of Secondary Tricuspid Regurgitation  Most common etiology of STR: RV dilation and dysfunction from LHD  The pathophysiology of STR may be divided into 3 phases: 1. Dilation of the right ventricle results in TA dilation 2. Progressive RV and TA dilation, failure of leaflet coaptation, and significant STR 3. Progressive RV distortion and eccentricity, tethering of the leaflets

Secondary Tricuspid Regurgitation  Significant tricuspid annular dilatation is defined by a diastolic diameter ≥40 mm or ≥21 mm/m² in the four- chamber transthoracic view.  Significant tethering coaptation distance >8 mm ESC 2012 VHD-Guidelines

The prevalence of STR  Degenerative mitral regurgitation 30% of patients have TR ≥2+ at the time of mitral surgery  Rheumatic mitral stenosis 30% of patients have TR ≥2+  ischemic mitral regurgitation 30% of patients have TR

Late TR  Significant TR occurring late after left-heart surgery is observed in up to 40% of patients, with a median survival of 5 years.  TV annuloplasty during mitral surgery results in a lower incidence of late TR.

TR-Echocardiography  2D Echo has the inherent limitation of not being able to show all three tricuspid leaflets together in the same view  Realtime 3D Echo (RT-3DE) has the unique capability of obtaining a short-axis plane of the TV

TR Quantification-EACI 2013  Normal tricuspid valve annulus diameter in adults is 28+5 mm in the four-chamber view (in diastole) Average TA circumference is 78 ± 7 mm/m²  Significant tricuspid annular dilatation is defined by a diastolic diameter of ≥21 mm/m² (>35 mm)  Tenting area >1 cm² is related severe TR

TR Quantification-EACI 2013 Colour Flow Imaging The colour flow area of the regurgitant jet is not recommended to quantify the severity of TR. Thecolour flow imaging should only be used for diagnosing TR.

TR Quantification-EACI 2013 VC width ≥7 mm defines severe TR. Poor accuracy of the in eccentric jets 3D EROA >75 mm²  severe TR (need validation)

TR Quantification-EACI 2013 Flow convergence method (PISA)  EROA ≥40 mm² or  RVol of ≥45 mL indicates severe TR. Quantitative but have several limitations-underestimates severity by 30%

TR Quantification-EACI 2013  Peak tricuspid inflow E velocity >1 m/s suggests severe TR  The systolic hepatic flow reversal is specific for severe TR. It represents the strongest additional parameter for evaluating the severity of TR.

TR Quantification-EACI 2013 Lancellotti P-EHJ-2013

RT3DE  The ability to visualize all three tricuspid leaflets simultaneously is a major advantage of RT3DE.  In TR patients, the tricuspid annulus tends to dilate in the septal-lateral and posteroseptal-to- anterolateral dimensions, resulting in a more circular and planar shape compared with healthy controls

3D-TEE RT-3D TEE data to describe the tricuspid annulus. Eccentric dilation seen in patients with TR. The tricuspid annulus shape is complex, with annular high and low points, and annular area calculation based on linear measurements significantly overestimates 3D planimetered area

Predictors of Unsuccessful TV Repair Preop RV dysfunction Severe TR Severe TV tethering Tenting area >1.63 cm² Tenting distance >0.76 cm Higher pulmonary artery pressures Increased LV remodeling Suture annuloplasty (De vega) Larger ring size MV replacement rather than repair Presence of pacemaker leads

Predictors of Late TR After Mitral Repair Katsi V-ICTS-2012 Dreyfus GD-Heart 2009 Tricuspid Anulus >70 mm at the surgical table or of >40 mm or 21 mm/m² at the echo imaging

Echocardiography and Surgical Technique  Ring annuloplasty should be performed in the presence of isolated annular dilatation.  Conversely, when severe annular dilatation and leaflet tethering are present, pericardial patch augmentation of the anterior leaflet or replacement of the TV should be considered.

ESC-2012-VHD  Predicting the evolution of functional TR after surgical treatment of mitral valve disease remains difficult. Pulmonary hypertension, increased RV pressure and dimension, reduced RV function, AF, pacemaker leads, and the severity of tricuspid valve deformation (tricuspid annulus diameter, coaptation height) are important risk factors for persistence or late worsening of TR.

ESC2012-VHD  Ring annuloplasty is key to surgery for TR. Better long-term results are observed with prosthetic rings than with the suture annuloplasty,  The incidence of residual TR being, respectively, 10% vs 20–35% at 5 years.

Indications for Tricuspid Valve Surgery ESC 2012 VHD- Guidelines Severe Right Ventricular Dysfunction????

Indications for Tricuspid Valve Surgery If secondary TR is less than severe, the diameter of the tricuspid annulus rather than the grade of regurgitation (which is highly subjective and variable) should be the criterion to indicate the need for concomitant TV repair at the time of mitral valve (MV) surgery

Assessment of RV Function The echocardiographic quantitative assessment of right ventricular (RV) function has been difficult owing to the complex RV anatomy. Identifying an accurate and reliable echocardiographic parameter for the functional assessment of the RV still remains a challenge

Assessment of RV Function  It has a complex geometry, appearing triangular when viewed from the front, and crescentic when viewed in a transverse section of the heart  Cannot be fitted to simple geometric models Limitation of 2D

Essential Imaging Windows and Views-1

Essential Imaging Windows and Views-2

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Right Heart Dimensions ASE 2010

Right Ventricle Dimensions The sensitivity of right ventricular sizewith angular change Ensure that the RVis not foreshortened and that the LVoutflow tract is not opened up (avoid the apical 5-chamber view)

RV Dimensions RV basal dimension <42 mm (RVD1)

RVOT Dimensions RVOT proximal diameter <33 mm RVOT proximal diameter <27mm

RV Systolic Function-FAC RV FAC = EDA-ESA/EDAX100 RV FAC <35% Prognostic value + Correlation with MRI derived EF

RV Systolic Function-2D RVEF 2D RV EF is not recommended, because of the heterogeneity of methods and the numerous geometric assumptions ASE 2010

RV Systolic Function-3D RVEF  Three-Dimensional Volume Estimation  RV end-diastolic volume <89 mL/m²  RV end-systolic volume <45 mL/m² (10% to 15% lower in women) The lower reference limit for RV EF is 44% Excellent correlation with MRI derived EF

RV Systolic Function-3D RVEF

RV MPI MPI = IVRT+IVCT/ET TissueDoppler derived MPI >0.55 RV dysfunction

TAPSE TAPSE may not reflect whole RV systolic function <16 mm RV dysf. Correlation with isotropic derived RVEF Prognostic value in HF

Doppler Tissue Imaging Cut-off value of 11.5 cm/s for tricuspid ring systolic velocities is able to accurately predict global RV dysfunction (defined as RVEF <45%).

Myocardial Acceleration During Isovolumic Contraction IVA measured in the basal segment of the RV free wall of > 1.1 m/s2 correlates well with MRI RVEF >45% (90% sensitivity and specificity). Angle dependent Load independent

RV Strain and Strain Rate (STE) Strain  Percentage change in myocardial deformation Strain rate  rate of deformation of myocardium over time Reflect regional and global RV functions Less load dependent

RV Strain and Strain Rate (STE)

LV eccentricity index (EccIx)  EccIx, defined as the ratio of the LV antero-posterior to septo- lateral diameters in a short-axis view  EccIx >1 at end-diastole  volume overload  Ecclx>1 at end systole and diastole  pressure overload

ASE-Right Heart Evaulation  Examine the right heart using multiple acoustic windows  Report should represent qualitative and quantitative parameters. RV size RA size RV systolic function (at least one of the following): Fractional area change [FAC] TAPSE S` SPAP

ESC 2012-VHD Guidelines  Evaluations of the RV dimensions and function should be conducted, despite existing limitations of current indices of RV function. TAPSE <15 mm St <11 cm/s RVED area > 0.20 cm² could be used to identify patients with RV dysfunction