Tricuspid Valve: An Intraoperative Echocardiographic Perspective

Abstract

FUNCTIONAL TRICUSPID REGURGITATION (FTR) is the most frequent presentation of tricuspid valve (TV) disease and often coexists with left-sided valve disorders. 1 Hung J. The pathogenesis of functional tricuspid regurgitation. Seminars in thoracic and cardiovascular surgery. 2010; 22: 76-78 Abstract Full Text Full Text PDF PubMed Scopus (39) Google Scholar There is considerable variation in the surgical approach to FTR during left-sided surgery from expectant management to TV repair in the presence of annular dilation. 2 Fawzy H, Fukamachi K, Mazer CD, et al: Complete mapping of the tricuspid valve apparatus using three-dimensional sonomicrometry. J Thorac Cardiovasc Surge 141:1037-1043 Google Scholar , 3 Gualis J. Castano M. Martinez-Comendador J.M. et al. Placement of a rigid tricuspid annuloplasty ring over a flexible ring for the treatment of recurrent tricuspid Regurgitation. J Cardi Surg. 2012; 27: 549-550 Crossref Scopus (1) Google Scholar , 4 Spinner E.M. Buice D. Yap C.H. et al. The effects of a three-dimensional, saddle-shaped annulus on anterior and posterior leaflet stretch and regurgitation of the tricuspid valve. Ann Biomed Eng. 2012; 40: 996-1005 Crossref PubMed Scopus (40) Google Scholar , 5 Ton-Nu T.T. Levine R.A. Handschumacher M.D. et al. Geometric determinants of functional tricuspid regurgitation: Insights from 3-dimensional echocardiography. Circulation. 2006; 114: 143-149 Crossref PubMed Scopus (264) Google Scholar The prognostic benefit of surgical treatment of FTR during left-sided valve surgery now is clearly established. 6 Sagie A. Schwammenthal E. Newell J.B. et al. Significant tricuspid regurgitation is a marker for adverse outcome in patients undergoing percutaneous balloon mitral valvuloplasty. J Ameri Coll Cardiol. 1994; 24: 696-702 Abstract Full Text PDF PubMed Scopus (114) Google Scholar , 7 Hornick P. Harris P.A. Taylor K.M. Tricuspid valve replacement subsequent to previous open heart surgery. J Heart Valve Dis. 1996; 5: 20-25 PubMed Google Scholar , 8 McCarthy P.M. Bhudia S.K. Rajeswaran J. et al. Tricuspid valve repair: Durability and risk factors for failure. J Thorac Cardiovasc Surg. 2004; 127: 674-685 Abstract Full Text Full Text PDF PubMed Scopus (540) Google Scholar Hence, there has been a resurgence of interest in the structure and function of the TV, which once was considered the “Cinderella” of cardiac valves. 2 Fawzy H, Fukamachi K, Mazer CD, et al: Complete mapping of the tricuspid valve apparatus using three-dimensional sonomicrometry. J Thorac Cardiovasc Surge 141:1037-1043 Google Scholar , 9 Ring L. Rana B.S. Kydd A. et al. Dynamics of the tricuspid valve annulus in normal and dilated right hearts: A three-dimensional transoesophageal echocardiography study. Eur Heart J Cardiovasc Imaging. 2012; 13: 756-762 Crossref PubMed Scopus (45) Google Scholar Assessment of tricuspid regurgitation (TR) severity generally is used as the basis of surgical decision-making during left-sided valve surgery. 10 Shiran A. Sagie A. Tricuspid regurgitation in mitral valve disease incidence, prognostic implications, mechanism, and management. J Am Coll Cardiol. 2009; 53: 401-408 Abstract Full Text Full Text PDF PubMed Scopus (241) Google Scholar However, echocardiographic assessment of TR is challenging in that it is load-dependent. Furthermore, the severity of TR is known to decrease after induction of general anesthesia. Whereas the presence of TR is considered a late sign of right ventricular (RV) dysfunction, tricuspid annular (TA) dilation is an early sign of potentially reversible RV dysfunction. 10 Shiran A. Sagie A. Tricuspid regurgitation in mitral valve disease incidence, prognostic implications, mechanism, and management. J Am Coll Cardiol. 2009; 53: 401-408 Abstract Full Text Full Text PDF PubMed Scopus (241) Google Scholar Due to the leaflets being poorly echogenic, the TA has been used to quantify the magnitude of valve remodeling due to chronic volume overload. 11 Maslow A.D. Schwartz C. Singh A.K. Assessment of the tricuspid valve: A comparison of four transesophageal echocardiographic windows. J Cardiothorac Vasc Anesth. 2004; 18: 719-724 Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar