Assessment of functional tricuspid regurgitation.

Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Via Giustiniani 2, Padua 35128, Italy.
European Heart Journal (Impact Factor: 14.72). 01/2013; DOI: 10.1093/eurheartj/ehs474
Source: PubMed

ABSTRACT Functional tricuspid regurgitation (FTR) is characterized by structurally normal leaflets and is due to the deformation of the valvulo-ventricular complex. While mild FTR is frequent and usually benign, patients with severe FTR may develop progressive ventricular dysfunction and incur increased mortality. Therefore, FTR should not be ignored, should be appropriately diagnosed and quantified by Doppler echocardiography, and should be evaluated for corrective surgical procedures. At present, referral for surgical correction of FTR is often delayed until patients develop intractable heart failure. However, this strategy frequently translates in poor clinical outcome characterized by notable operative mortality and reduced long-term survival. Appropriate patient selection and proper timing for tricuspid valve (TV) repair or replacement are crucial for optimal outcome, but objective criteria for clinical decison-making remain poorly defined. In the present paper, we review the anatomy of the normal TV, the pathophysiology of FTR, the assessment of its severity and functional significance, and propose an algorithm for selecting patients for surgical treatment.

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    ABSTRACT: The aim of this study was to assess the outcome of isolated tricuspid regurgitation (TR) and the added value of quantitative evaluation of its severity. TR is of uncertain clinical outcome due to confounding comorbidities. Isolated TR (without significant comorbidities, structural valve disease, significant pulmonary artery systolic pressure elevation by Doppler, or overt cardiac cause) is of unknown clinical outcome. In patients with isolated TR assessed both qualitatively and quantitatively by a proximal isovelocity surface area method, a long-term outcome analysis was conducted. Patients with severe comorbid diseases were excluded. The study involved 353 patients with isolated TR (age 70 years; 33% male; ejection fraction, 63%; all with right ventricular systolic pressure <50 mm Hg). Severe isolated TR was diagnosed in 76 patients (21.5%) qualitatively and 68 patients (19.3%) by quantitative criteria (effective regurgitant orifice [ERO] ≥40 mm(2)). Ten-year survival and cardiac event rates were 63 ± 5% and 29 ± 5%. Severe isolated TR independently predicted higher mortality (adjusted hazard ratio: 1.78 [1.10 to 2.82], p = 0.02 for qualitative definition and 2.67 [1.66 to 4.23] for an ERO ≥40 mm(2), p < 0.0001). The addition of grading by quantitative criteria in nested models eliminated the significance of the qualitative grading and improved the model prediction (p < 0.001 for survival and p = 0.02 for cardiac events). The 10-year survival rate was lower with an ERO ≥40 mm(2) versus <40 mm(2) (38 ± 7% vs. 70 ± 6%; p < 0.0001), independent of all characteristics, right ventricular size or function, comorbidity, or pulmonary pressure (p < 0.0001 for all), and lower than expected in the general population (p < 0.001). Freedom from cardiac events was lower with an ERO ≥40 mm(2) versus <40 mm(2) independently of all characteristics, right ventricular size or function, comorbidity, or pulmonary pressure (p < 0.0001 for all). Cardiac surgery for severe isolated TR was rarely performed (16 ± 5% 5 years' after diagnosis). Isolated TR can be severe and is associated with excess mortality and morbidity, warranting heightened attention to diagnosis and quantitation. Quantitative assessment of TR, particularly ERO measurement, is a powerful independent predictor of outcome, superior to standard qualitative assessment. Copyright © 2014 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.
    JACC Cardiovascular Imaging 11/2014; 7(12). DOI:10.1016/j.jcmg.2014.07.018 · 6.99 Impact Factor
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    ABSTRACT: Abstract Background: Functional tricuspid regurgitation is a challenge regarding indications for repair and proper surgical technique. Aim of the study: We reviewed our midterm results of tricuspid valve repair for functional regurgitation comparing pericardial strip versus ring annuloplasties. Patients and methods: From January 2008 to December 2013, we operated 59 patients (male:female, 41:18, with a mean age of 34 ± 14 years) for functional tricuspid regurgitation. Tricuspid annuloplasty was done using pericardial strip in 39 patients and ring in 20 patients. Concomitant procedures were mitral valve replacement in 66% of patients, aortic valve replacement in 5% and double valve replacement in 29%. Clinical and echocardiographic data were collected. Results: Preoperative characteristics of the two groups were similar regarding age, percentage of female patients, New York Heart Association functional class and pulmonary artery pressure. More patients with preoperative right ventricular dysfunction were found in pericardial annuloplasty group although this was not statistically significant (13 versus 5; P = 0.52). Operative times were similar in both groups. We had one mortality case (1.69%) due to low cardiac output in the pericardial group. Postoperative complications included reexploration for bleeding in one patient and chronic heart failure in another patient. The average follow up period was 3 years and it was complete in 100% of patients. Postoperative freedom from recurrent moderate tricuspid regurgitation was 90% in both groups. Conclusion: Pericardial strip annuloplasty is a simple, inexpensive, reproducible and efficient technique that has comparable results to ring annuloplast
    World Journal of Cardiovascular Surgery 01/2014; DOI:10.4236/wjcs.2014.412035
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    ABSTRACT: Tricuspid annular (TA) size and function play important roles in planning the need for associated TA annuloplasty in patients undergoing cardiac surgery for left-sided heart valve diseases. However, TA diameter normative values and the extent of TA dynamic changes during cardiac cycle remain to be established. This was a prospective, cross-sectional study of 219 healthy volunteers (mean age, 43 ± 15 years; 57% women), using conventional two-dimensional transthoracic echocardiographic (2DE) imaging to assess the variability of TA diameter measurement in relation to 2DE view and timing during cardiac cycle. TA diameter was obtained from apical right ventricular (RV)-focused four-chamber, parasternal long-axis RV inflow, and parasternal short-axis at aortic plane 2DE views at five time points during the cardiac cycle. Right atrial and RV volumes were measured using three-dimensional echocardiography. TA diameters differed significantly among the three 2DE views and changed significantly during the cardiac cycle in all views. Moreover, mean fractional shortening of TA diameter was 24 ± 6% in the four-chamber view, 20 ± 7% in the parasternal long-axis RV inflow view, and 29 ± 11% in the parasternal short-axis at aortic plane view. One multivariate linear regression analysis, age, gender, and right atrial and RV volumes were independently correlated with TA diameters and accounted for 55% of the variance of midsystolic TA diameter in the four-chamber view. This study provides references values for TA diameters and dynamics using 2DE imaging. Age, gender, and right chamber sizes, as well as the 2DE view and time during the cardiac cycle, significantly influenced TA diameters in healthy individuals. These data may help better identify TA dilatation using 2DE imaging for surgical planning. Copyright © 2014 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.
    Journal of the American Society of Echocardiography: official publication of the American Society of Echocardiography 10/2014; 28(2). DOI:10.1016/j.echo.2014.09.017 · 2.98 Impact Factor


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May 15, 2014