Tricuspid Annular Dimensions Research Articles

Three-Dimensional Transthoracic Echocardiography for Semiautomated Analysis of the Tricuspid Annulus: Validation and Normal Values

The expansion of tricuspid valve (TV) interventions has underscored the need for accurate and reproducible three-dimensional (3D) transthoracic echocardiographic (TTE) tools for evaluating the tricuspid annulus and for 3D normal values of this structure. The aims of this study were to develop new semi-automated software for 3D TTE analysis of the tricuspid annulus, compare its accuracy and reproducibility against those of multiplanar reconstruction (MPR) reference, and determine normative values. Three-dimensional TTE images of 113 patients with variable degrees of tricuspid regurgitation were analyzed using the new semiautomated software and conventional MPR methodology (as the reference standard), each by three independent readers. For each measured parameter, intertechnique agreement was assessed using linear regression and Bland-Altman analyses, and interreader variability using intraclass correlation coefficients and coefficients of variation. Additionally, 3D TTE data sets of 789 subjects from the WASE (World Alliance Societies of Echocardiography) study were analyzed using this new software to determine normal values for each tricuspid annular (TA) parameter. Semiautomated measurements showed excellent agreement with MPR reference values for all TA measurements: high correlations (all r values >0.8) and minimal biases. All measurements were more reproducible than with MPR: higher intraclass correlation coefficients (0.94-0.96 vs 0.82-0.90) and lower coefficients of variation (5%-12% vs 8%-18%). Sex- and age-related differences were identified in 3D normal values of most TA parameters. Dynamic analysis showed that TA parameters vary throughout the cardiac cycle, reaching minimal values at end-systole and maximum values in late diastole. Novel software for semiautomated analysis of TA geometry and dynamics provides accurate and reproducible measurements. Normal values of TA dimensions, parsed by sex and age, are reported.

Three-Dimensional Speckle-Tracking Echocardiography-Derived Tricuspid Annular Properties in Acromegaly-Results from the MAGYAR-Path Study.

Acromegaly is an endocrine pathology characterized by the overproduction of human growth hormone. The present study aimed to analyze three-dimensional speckle-tracking echocardiography (3DSTE)-derived tricuspid annular (TA) properties in detail in patients with acromegaly and to compare the findings to those of matched healthy controls. The present study consisted of 29 patients with acromegaly (mean age: 55.9 ± 14.5 years, 21 males), of which 13 had an active disease. The control population comprised 57 healthy subjects (mean age: 53.2 ± 8.4 years, 38 males). In the presence of acromegaly, left atrial and end-diastolic left ventricular (LV) sizes were dilated, and LV ejection fraction was increased, which was accompanied by thickened interventricular septum and LV posterior wall as compared with matched healthy controls. The presence of grade 1 mitral (MR) and tricuspid (TR) regurgitations were more frequent in acromegaly than in controls, regardless of disease activity. Higher than grade 1 MR/TR was uncommon in acromegaly. The 3DSTE-derived all end-diastolic (2.47 ± 0.27 cm vs. 2.23 ± 0.27 cm; 8.73 ± 1.77 cm2 vs. 6.67 ± 1.40 cm2; 11.56 ± 1.34 cm vs. 10.20 ± 1.10 cm, p < 0.001 for all) and end-systolic (1.97 ± 0.27 cm vs. 1.77 ± 0.28 cm; 6.24 ± 1.61 cm2 vs. 5.01 ± 1.42 cm2; 9.80 ± 1.35 cm vs. 8.72 ± 1.10 cm, p < 0.001 for all) TA diameters, areas, and perimeters proved to be dilated, while TA functional parameters including TA fractional area change (28.77 ± 9.80% vs. 27.64 ± 15.34%, p = 0.720) and fractional shortening (20.60 ± 9.08% vs. 20.51 ± 8.81%, p = 0.822) were normal in acromegaly regardless of whether acromegaly was active or not. RA volumes respecting the cardiac cycle were dilated in acromegaly as compared with those of healthy controls regardless of disease activity and were associated with respective changes in TA dimensions. In the presented acromegaly patients, significant TA dilation with preserved function could be detected regardless of disease activity. RA volumes and TA dimensions are correlated in acromegaly.

Comparison of Tricuspid Annular Dimension Measurements Using Automated Three-Dimensional Transthoracic Echocardiography and Computed Tomography in Patients Evaluated for Transcatheter Tricuspid Valve Intervention

Comparison of Tricuspid Annular Dimension Measurements Using Automated Three-Dimensional Transthoracic Echocardiography and Computed Tomography in Patients Evaluated for Transcatheter Tricuspid Valve Intervention

Cardiac Mechanics and Valvular and Vascular Abnormalities in Hypereosinophilic Syndrome.

Hypereosinophilic syndrome (HES) is considered to be a rare myeloproliferative disease that is characterized by persistent eosinophilia with associated multiple-organ damage. The heart is often involved in HES, representing a major cause of morbidity and mortality. HES is a heterogeneous group of disorders; the majority of the cases are idiopathic. Summarizing the findings regarding myocardial, valvular, and vascular abnormalities in a series of patients with HES, most studies found normal left ventricular (LV) volumes with reduced LV global longitudinal strain and LV apical rotation and twist in HES cases, accompanied by increased left atrial (LA) volumes and stroke volumes, reduced peak LA circumferential strain (representing systolic abnormalities), and mitral annular dilation and functional deterioration. Regarding the right heart, preserved right ventricular volumes and functional properties, increased right atrial volumes, mild RA functional abnormalities, and dilated tricuspid annular dimensions without functional impairment could be seen in these studies. Aortic and pulmonary valves showed no specific disease-related alterations. Vascular abnormalities included increased aortic stiffness without dilation of the aorta and pulmonary hypertension in some cases. These results suggest disease-specific but relatively mild myocardial, valvular, and vascular abnormalities in HES. The present review aimed to summarize the available clinical data about cardiac mechanics and valvular and vascular abnormalities in a series of patients with HES.

The Relationship between Tricuspid Annular Longitudinal and Sphincter-like Features of Its Function in Healthy Adults: Insights from the MAGYAR-Healthy Study.

The tricuspid valve is an atrioventricular valve located on the right side of the heart, which consists of the fibrous tricuspid annulus (TA), three valvular leaflets and a supporting apparatus, the papillary muscles and the tendinous chords. The TA is an oval-shaped three-dimensional (3D) fibrous structure with a complex spatial movement during the cardiac cycle. Three-dimensional echocardiography (3DE) could help during "en-face" assessment of TA dimensions and related functional properties featuring its "sphincter-like" function. TA plane systolic excursion (TAPSE) is a displacement of the lateral edge of the TA toward the apex in systole measured in apical long-axis using M-mode echocardiography (MME). The aim of this study was to determine potential relationships between TA size and its "sphincter-like" and "longitudinal" functions in healthy adults with no functional tricuspid regurgitation. The present study consisted of 119 healthy patients (age: 34.6 ± 11.5 years, 70 men) who underwent routine echocardiography with M-mode-derived TAPSE measurement and 3DE. Two subgroups of healthy subjects were compared with each other. A total of 29 subjects with TAPSE between 17 and 21 mm were compared with 90 cases with TAPSE ≥ 22 mm. Subjects with TAPSE of 17-21 mm had tendentiously dilated TA dimensions compared with subjects with TAPSE ≥ 22 mm. Significant differences could be detected in the end-systolic TA area (5.85 ± 1.90 cm2 vs. 3.70 ± 1.22 cm2, p < 0.05), leading to impaired TAFAC (24.8 ± 9.0% vs. 35.1 ± 9.1%, p < 0.05) in subjects with lower TAPSE (17-21 mm) compared with subjects with TAPSE ≥ 22 mm. TAPSE did not show correlations with any TA size or "sphincter-like" functional parameters as determined using 3DE. Three-dimensional echocardiography is capable of measuring TA dimensions and functional "sphincter-like" properties, which are associated with MME-derived TAPSE, suggesting a sensitive and harmonic TA function in healthy adults without functional tricuspid regurgitation.

Failure of Tricuspid Annuloplasty for Functional Tricuspid Regurgitation: Impact of Patient's Body Size

Tricuspid repair is recommended for significant functional tricuspid regurgitation (FTR) or tricuspid annulus (TA) dilation, based on TA >40mm or >21mm/m². The concordance between both TA dimensions related to the patient's body size has not been investigated. Patients who underwent rigid ring tricuspid annuloplasty for FTR between 2009 and 2017 were included. Assuming equality between both TA diameter criteria, patients were divided per body surface area (BSA): group 1=BSA ≤1.9m² and group 2=BSA >1.9m². The primary outcome was TR recurrence at 5years. Tricuspid annuloplasty was performed in 186 patients (group 1: 130 patients [69.9%]; group 2: 56 patients [30.1%]). Group 1 comprised more female (70.8% to 23.2%, p <0.001) and older patients (77.1 ± 9.3 years; 74.2 ± 8.2 years, p=0.048). Group 1 had a smaller absolute TA diameter (group 1: 45.3 ± 5.2mm; group 2: 48.2 ± 5.6mm, p <0.001), whereas the indexed TA size was inversely higher (group 1: 26.3 ± 3.4mm/m²; group 2: 24.2 ± 2.7mm/m², p <0.001). The tenting height was comparable (group 1: 7.8 ± 3.0mm; group 2: 8.0 ± 2.7mm, p=0.714). The median ring size was 30 (interquartile range 28 to 32) and 32 (interquartile range 30 to 34) for groups 1 and 2, respectively (p <0.001). TR recurrence at 5years was noticed in 20.2% and 6.5% of group 1 and 2 (p=0.035). Indexed TA diameter (hazard ratio 1.43, 95% confidence interval 1.10 to 1.87, p=0.008) and tenting height (hazard ratio 5.52, 95% confidence interval 1.87 to 14.57, p=0.002) were independent predictors of TR recurrence. In conclusion, when the absolute TA diameter is used as the primary criterion, smaller patients are at a higher risk for TR recurrence by having a proportionally larger TA at the time of repair. An individualized approach guided by patient's body size might be more appropriate to indicate FTR correction to adjust for the annuloplasty sizing method.

Tricuspid annular and right atrial volume changes are associated in healthy adults-insights from the three-dimensional speckle-tracking echocardiographic MAGYAR-Healthy Study.

The tricuspid valve and its annulus (TA) and the right atrium (RA) play a significant role in regulating blood flow in the right heart. However, their effect on each other is not fully understood even in normal circumstances. Three-dimensional (3D) speckle-tracking echocardiography (3DSTE) is able to simultaneously assess TA and RA at the same time in a non-invasive way. The present study aimed to examine associations between tricuspid annular (TA) dimensions and right atrial (RA) volumes in healthy adults by 3DSTE. The present study comprised 144 healthy subjects (mean age: 34.4 ± 12.6 years, 72 males), who participated in this study on a voluntary basis for screening between 2011 and 2015. In all subjects, electrocardiography, two-dimensional Doppler echocardiography and 3DSTE have been performed. With increasing end-systolic maximum RA volume, all end-systolic and end-diastolic TA dimensions showed simultaneous increase, but in various degrees resulting in (non-significant) reduction of TA functional properties. Similarly, with increasing diastolic pre-atrial contraction and minimum RA volumes, TA dimensions increased simultaneously (except end-diastolic TA diameter), but in various degrees resulting in reduced TA fractional shortening and fractional area change. With increasing RA dimensions, end-systolic and end-diastolic TA dimensions showed simultaneous increase, but in different, sometimes not significant degrees. While RA stroke volumes showed increasing pattern with TA dilation, RA emptying fractions have not changed substantially. 3DSTE is suitable for non-invasive assessment of TA dimensions and RA volumes at the same time using the same 3D echocardiographic dataset. Significant associations between TA size and RA volumes exist in healthy circumstances. Strong associations in case of dilation of TA in the presence of higher RA volumes could partly explain functional tricuspid regurgitation later developing in subjects in sinus rhythm.

Three-Dimensional Speckle-Tracking Echocardiography-Derived Tricuspid Annular Dimensions and Right Atrial Strains in Healthy Adults-Is There a Relationship? (Insights from the MAGYAR-Healthy Study).

The tricuspid valve and its annulus (TA) are thought to be integrally related to right atrial (RA) size and function. The present study aimed to assess associations between TA dimensions and RA strains, and quantitative features of its contractility were determined by 3DSTE in healthy adults. The study comprised 145 healthy volunteers with a mean age of 34.4 ± 12.5 years (73 males). Electrocardiographic, two-dimensional Doppler echocardiographic and 3DSTE parameters were in normal reference ranges in all subjects. Enlarged TA areas, regardless of which phase of the cardiac cycle were measured, were not associated with the deterioration of peak RA strains in longitudinal (LS) and circumferential (CS) directions. Increased end-diastolic TA area was associated with reduced RA strain in the radial direction (RS). Dilation of end-diastolic and end-systolic TA areas was related to increased RA volumes. End-diastolic TA area was the smallest in case of increased peak global RA-RS, and other associations between increasing TA areas and peak global strains could not be detected. Peak global RA-CS and RA-LS were not related to TA areas. Increasing peak global RA-RS was not associated with peak global RA-LS and RA-CS, while increasing peak global RA-LS and RA-CS were not associated with peak global RA-RS. Increasing peak global RS did not show associations with RA volumes, Vmin was the smallest in the case of highest peak global RA-CS and RA-LS. Vmax increased with increasing peak global RA-LS. 3DSTE is suitable for simultaneous non-invasive determination of TA dimensions and RA volumes and strains using the same acquired 3D dataset, allowing physiologic studies. RA volumes are associated with end-diastolic and end-systolic TA areas. RA strains in radial direction (RS) show associations with end-diastolic TA area.

The Early Effects on Tricuspid Annulus and Right Chambers Dimensions in Successful Tricuspid Valve Bicuspidization.

It is unclear to what degree of tricuspid annulus (TA) reduction is necessary to achieve good postoperative results in surgical bicuspidization. The study aimed to evaluate TA and right heart chamber's dimensions before and after heart surgery; and to compare TA parameters assessed by different modalities. Forty patients underwent mitral valve surgery with or without concomitant tricuspid valve (TV) bicuspidization. Preoperative and postoperative measurements of TA dimensions were performed prospectively using two-dimensional (2D) and three-dimensional (3D) transthoracic echocardiography (TTE). Additionally, preoperative transesophageal echocardiography (TOE) was performed in the operating room prior to surgery. All patients had no or mild TR immediately after surgery. There was a significant reduction in 2D and 3D parameters of the TV and right chambers in the TV bicuspidization group. However, TV leaflets' tethering parameters did not change significantly. Preoperative 3D TTE measurements were smaller than those obtained through 3D TOE in the operation room, before surgery under general anesthesia. The 2D systolic apical 4Ch diameter and the parasternal short axis diameter mainly represent the 3D minor axis of the TA and are smaller than its 3D major axis. Although bicuspidization results in a one-third reduction of the TV area, tethering of the TV leaflets remains unchanged. Moreover, 3D TOE parameters of the TV under general anesthesia are larger than preoperative 3D TTE measurements. Conventional 2D measurements are insufficient for evaluating the maximum diameter of the TA.

Comparison between multimodality imaging approaches for measurement of the tricuspid annulus in severe tricuspid regurgitation

BackgroundTricuspid valve (TV) sizing is crucial for surgical or interventional procedures planning. Imaging TV is frequently challenging and often requires multimodal imaging techniques. Computed tomography (CT) is the gold standard for sizing. The authors compared measurements of the tricuspid annulus (TA) acquired using echocardiography and CT. MethodsThirty-six patients with severe symptomatic tricuspid regurgitation were included in this retrospective analysis. During mid-diastole, the maximal two-dimensional (2D) TA diameter was directly measured in multiple views using transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE). Three-dimensional (3D) TA size was assessed using cross-sectional long-axis and short-axis diameters, areas, and perimeters measured in the projected plane. The TA diameter was quantified by the perimeter measured on the CT images (CT imaging_indirect) and compared with echocardiography measurements. Tenting height and tenting area were also measured using TTE at mid systole. ResultsThe long-axis dimensions measured using 3DTEE (3DTEE_direct) best correlated with the TA diameter (CT imaging_indirect) (R = 0.851, P = 0.0001) and the least discrepancies (difference 1.2 ± 2.4 mm, P = 0.012). The TA diameters quantified by the perimeters measured using 3DTEE (3DTEE_indirect) were smaller than the CT values (difference 2.5 ± 2.5 mm, P = 0.0001). The maximal dimensions directly measured by 2DTEE (2DTEE_direct) were modestly correlated with the CT values. Overall, the maximal dimensions by TTE_direct were less reliable than those by CT. TA eccentricity index correlated with the maximal tenting height and area. ConclusionThe patients with severe tricuspid regurgitation had a dilated and circular annulus. The long-axis TA dimensions (3DTEE_direct) were similar to the diameters (CT imaging_indirect).

Dynamic assessment of the tricuspid annulus in a healthy Asian population: A four-dimensional echocardiography study.

Tricuspid annulus (TA) geometry and function reference values are limited, especially for Asian populations. We aimed to explore TA using four-dimensional echocardiography (4DE) in a healthy Asian population. A total of 355 healthy Asian volunteers (median age 34 years; 52% males) were prospectively enrolled. TA geometry and function were analyzed using 4DE throughout the cardiac cycle. The TA area, perimeter, and dimensions were smallest at end systole (ES) and largest at late diastole (LD). Normal TA parameters at end diastole (ED) in different sex and age groups were obtained. TA areas, perimeters, and dimensions in males were significantly larger than those in females at ED; BSA-indexed perimeters and BSA-indexed dimensions in males were significantly smaller than those in females at ED. TA parameters correlated well with tricuspid valve (TV) tenting, right ventricle (RV), and right atrium (RA) parameters. Reference values of TA parameters were obtained by 4DE in an Asian population. Quantitative data on TA geometry and function are essential for TA pathology and therapeutics.

Normal reference values of tricuspid annular dimensions and functional properties in healthy adults using three-dimensional speckle-tracking echocardiography (insights from the MAGYAR-Healthy Study)

Three-dimensional speckle-tracking echocardiography (3DSTE) is a relatively new non-invasive imaging modality with ability for simultaneous chamber quantifications and determination of valvular dimensions. The aim of the present retrospective cohort study was to determine normal reference values of 3DSTE-derived tricuspid annular (TA) dimensions and functional properties and to evaluate their age- and gender dependency. The present study comprised 156 healthy adult subjects, from which 28 cases were excluded due to inferior image quality, therefore the remaining group consisted of 128 cases with the mean age of 35.4±12.5 years (72 males). The subject population was further divided into the following categories: 18-29 years (n=57; mean age: 25.2±2.8 years, 51 males), 30-39 years (n=29; mean age: 34.1±2.5 years, 31 males), 40-49 years (n=17; mean age: 44.1±3.2 years, 11 males) and ≥50 years of age (n=25, mean age: 59.2±6.4 years, 14 males). End-diastolic TA diameter (2.2±0.3 vs. 2.5±0.3 cm, P<0.05), area (7.1±1.3 vs. 8.1±1.7 cm2, P<0.05) and perimeter (10.3±0.9 vs. 11.0±1.2 cm, P<0.05) were lower in females than in males in the 18-29 year-old group and TA area (6.1±0.8 vs. 8.0±1.2 cm2, P<0.05) and TA perimeter (9.7±0.8 vs. 11.0±0.9 cm, P<0.05) were lower in females than in males in the 40-49 year-old group. End-systolic TA diameter were lower in females than in males in the 18-29 year-old group (1.8±0.2 vs. 1.9±0.3 cm, P<0.05) and TA area (4.7±0.3 vs. 6.3±1.2 cm2, P<0.05) and TA perimeter (8.6±0.4 vs. 9.5±0.9 cm, P<0.05) were lower in females than in males in the 40-49 year-old group. TA fractional area change was found to be reduced in the 40-49 year-old group as compared to the 30-39 year-old group (21.7%±8.7% vs. 29.2%±10.0%, P<0.05). 3DSTE is a novel method for non-invasive assessment of TA dimensions and functional properties. Results highlight the importance of age- and gender-specific reference values in case of TA diameter, area and perimeter and calculated functional features respecting the cardiac cycle.

Abstract 10766: Analysis of Cardiac Ct Anatomy in Patients With Severe Tricuspid Regurgitation Considered for Transcatheter Intervention

Introduction: Severe tricuspid regurgitation (TR) is associated with considerable morbidity/mortality in an elderly population with multiple comorbidities. There is interest in transcatheter interventions to manage severe TR in this population. Understanding right heart (RH) anatomy has implications for patient/device selection for transcatheter intervention. Hypothesis: We analyzed RH anatomy by CT of patients referred for TR therapy to determine transcatheter tricuspid intervention device sizing needs. Methods: Retrospective Mayo Clinic study of 29 patients considered for intervention of severe TR from 3/1/2016-12/15/2020; echocardiogram and CT angiogram obtained in all patients. Results: Mean age was 83±8 (83% female), 100% had atrial fibrillation, and 62% had chronic kidney disease ≥3a. 97% were symptomatic, 93% were prescribed loop diuretics, and 24% had device leads. Mean tricuspid annular plane systolic excursion 16.8±4.5 mm, effective regurgitant orifice area (EROA) 81±33 mm 2 , and cardiac index 2.6±0.6 L/min/m 2 . 41% had at least moderate right ventricular (RV) dysfunction with a mean RV systolic pressure of 46±16 mmHg. Patients receiving intervention had significantly larger EROA (101±33 v. 63±22 mm 2 , P=0.033), shorter tricuspid leaflet tenting length (6.5±3.0 v. 8.9±2.7 mm, P=0.042), and smaller annuloplasty diagnostic perimeter during diastole (120.1±16.6 v. 131.1±7.4 mm, P=0.041). Intervention patients tended to have better right ventricular function, smaller RV and IVC size, and more severe symptoms. Max tricuspid annulus diameter in systole and diastole was 51±5 and 53±7 mm, respectively. Conclusions: Severe TR patients referred for transcatheter intervention present with severe RH enlargement with a large proportion having tricuspid annulus dimensions outside the range for current devices available in clinical trials. These data have implications for device development/selection and procedural feasibility.

Analysis of Cardiac Computed Tomography Anatomy in Patients With Severe Tricuspid Regurgitation Considered for Transcatheter Intervention

BackgroundSevere tricuspid regurgitation (TR) is associated with considerable morbidity/mortality in an elderly population with multiple comorbidities. There is interest in transcatheter interventions to manage severe TR. Understanding complex right heart (RH) geometry and tricuspid valve shape and size has implications for patient/device selection for transcatheter intervention. We characterized RH anatomy by computed tomography in patients with symptomatic severe TR considered for intervention. MethodsThe retrospective Mayo Clinic study included 29 patients with an echocardiogram and cardiac computed tomography angiogram considered for intervention of severe TR from March 01, 2016 to December 15, 2020. Patients were divided into 2 groups: intervention (surgical or transcatheter; n = 17) and medical management alone (n = 12). ResultsMean age was 83 ± 8 (83% female), 100% had atrial fibrillation, and 62% had chronic kidney disease ≥3a. Ninety-seven percent were symptomatic, 93% had been prescribed loop diuretics, and 24% had device leads. Mean tricuspid annular plane systolic excursion was 16.8 ± 4.5 mm, effective regurgitant orifice area was 81 ± 33 mm2, and cardiac index was 2.6 ± 0.6 L/min/m2. Forty-one percent had at least moderate right ventricular (RV) dysfunction with a mean RV systolic pressure of 46 ± 16 mmHg. Patients receiving intervention had significantly larger effective regurgitant orifice area (101 ± 33 vs. 63 ± 22 mm2, p = 0.033), shorter tricuspid leaflet tenting length (6.5 ± 3.0 vs. 8.9 ± 2.7 mm, p = 0.042), and smaller annuloplasty diagnostic perimeter during diastole (120.1 ± 16.6 vs. 131.1 ± 7.4 mm, p = 0.041). Intervention patients tended to have better right ventricular function, smaller RV and inferior vena cava size, and more severe symptoms. The maximal tricuspid annulus diameter in systole and diastole was 51 ± 5 and 53 ± 7 mm, respectively. ConclusionsSevere TR patients referred for transcatheter intervention present with severe RH enlargement with a large proportion having tricuspid annulus dimensions outside the range for current devices available in clinical trials. The presented data have implications for device development/selection and procedural feasibility.

Tricuspid Annular Abnormalities in Isolated Left Ventricular Non-compaction-Insights From the Three-dimensional Speckle-Tracking Echocardiographic MAGYAR-Path Study.

IntroductionProminent trabecular left ventricular (LV) meshwork and deep intertrabecular LV recesses are featuring LV non-compaction (LVNC). The aim of this study was to evaluate tricuspid annular (TA) morphological and functional abnormalities by three-dimensional speckle-tracking echocardiography (3DSTE) in patients with LVNC without right ventricular (RV) involvement.Materials and MethodsThis study consisted of 21 patients with isolated LVNC, from which 6 cases were excluded due to inferior image quality. The remaining patient group consisted of 15 subjects with a mean age of 52.1 ± 11.4 years (9 males). LVNC was defined according to the Jenni's criteria. Their results were compared to 21 age- and gender-matched healthy controls (mean age: 52.4 ± 3.9 years, 14 males). Complete routine 2-dimensional Doppler echocardiographic examination was performed in all the patients with isolated LVNC and healthy controls. End-systolic and end-diastolic TA dimensions were assessed on selected planes derived from full-volume 3D echocardiographic datasets during 3DSTE.ResultsPatients with isolated LVNC showed significantly dilated end-systolic and end-diastolic TA diameter and area, which were accompanied with preserved TA functional properties and associated with right atrial (RA) volumes. TA plane systolic excursion (TAPSE) showed mild correlations with TA fractional area change (TAFAC) and TA fractional shortening (TAFS). No correlations could be demonstrated between TAPSE and TA morphological features. Extent of LVNC did not correlate with any echocardiographic parameters.ConclusionTA is dilated with preserved sphincter-like function in patients with isolated LVNC. Longitudinal (TAPSE) and sphincter-like (TAFAC and TAFS) TA movements correlate with each other. TA dilation is associated with an increased RA volumes respecting cardiac cycle.

Effect of interventional edge-to-edge repair in tricuspid regurgitation on dimensions of the annulus

Abstract Funding Acknowledgements Type of funding sources: None. Background The technique of percutaneous tricuspid valve edge-to-edge repair (pTVR) depends upon the connection of leaflets in the area of regurgitation using a coaptation device. By closing the coaptation device a considerable tractive force is applied on the leaflets, which might have an effect on the valve annulus. The aim of this study was to examine the impact of device implantation on tricuspid annular dimensions. Methods During pTVR, 3D zoom loops of the tricuspid valve (TV) were acquired before and after clip placement using transesophageal echocardiography. Measurements of TV annular dimensions included the following parameters: annulus area (TV area), maximal diameter, minimal diameter, and eccentricity index (Figure 1). Tenting area was derived from a four-chamber view of the valve. Tricuspid regurgitation (TR) severity was graded from 1+ to 5+ by measuring vena contracta area (VCA3D) in 3D full volume color Doppler loop using multiplanar reconstruction. Right atrial (RA) and ventricular volumes (RVVd3D, RVVs3D) and function (RVEF3D) were assessed in a 3D full volume loop. Results The study population consisted of 97 patients (age 78 ± 6 years, 47 male), undergoing pTVR at our hospital. As expected, cavity dimension correlated with TV area size (for RVVd3D r = 0.51, p &amp;lt; 0.001 and for RA volume r = 0.71, p &amp;lt; 0.001). The mean TV annular area was significantly reduced (Annular area 8.53 ± 2.23 cm²/m²BSA vs. 7.55 ± 2.18 cm²/m²BSA, p &amp;lt; 0.001) and the shape of the annulus became more oval (Eccentricity index 1.2 ± 0.15 vs. 1.29 ± 0.17, p &amp;lt; 0.001) after pTVR. The reduction in annular area (12 ± 7%, range 0.7-28%) was only modestly correlated with the number of implanted coaptation devices (r = 0.30, p &amp;lt; 0.001) and the percentage reduction of VCA3D (r =0.36, p &amp;lt; 0.001). In the patient group with an annular area change ≥12%, a decrease in TR grade to ≤2+ by pTVR was achieved in 83% of cases, whereas only 62% of patients achieved moderate TR when the change in area was below 12%. Conclusion pTVR using coaptation devices reduces the area of the TV annulus. This effect may be modestly correlated to the number of devices implanted. Abstract Figure.

Prognostic value of three-dimensional echocardiographic assessment of tricuspid valve geometry and parameters of severity in atrial and ventricular functional tricuspid regurgitation

Abstract Funding Acknowledgements Type of funding sources: None. Background Atrial and ventricular functional tricuspid regurgitation (A-FTR and V-FTR) have recently emerged as different phenotypes of FTR. Given the difference in mechanisms that are postulated to be underlying these 2 entities, a different remodeling of tricuspid valve (TV) apparatus can occur and therefore also a specific quantitative approach could be deemed. Aim Aim of this study was to investigate the TV apparatus remodeling in the two different phenotypes of FTR: ventricular (V-FTR) and atrial (A-FTR) and the role of echocardiographic parameters of TV remodeling and TR severity to predict clinical outcomes. Material and methods The present retrospective study included consecutive patients with moderate to severe functional tricuspid regurgitation (FTR) referred for echocardiography in two Italian centers. The composite endpoint of death for any cause and heart failure (HF) hospitalization was used as primary outcome of this analysis. According to more recent guidelines, patients were considered having A-FTR if having history of long- standing atrial fibrillation, without history of pulmonary hypertension and left side heart disease. Results. A total of 180 patients were included. Despite the right atrial volume (RAV) was not different in the 2 groups, in A-FTR tethering height was significantly lower (11.7 ±4.8 mm vs 15.0 ± 5.5 in V-FTR. p &amp;lt;0.01) and the 3D-derived tricuspid annulus (TA) diameters were larger both in end-diastolic and mid-systolic phase (3D-TA-End diastolic- major axis: 45.2 ± 6.2 mm in A-FTR vs 42.8 ± 5.4 in V-FTR. p= 0.04; 3D-TA mid systolic major axis: 41,7 ± 6,4mm in A-FTR vs 37,9 ± 5,1 in V-FTR, P &amp;lt;0,01). 3D-TA-End diastolic- minor axis: 39.7 ± 6.8 vs 37.1 ± 5.2. p= 0.03). Regarding the parameters of severity of FTR. patients with V-FTR had larger vena contracta (VC). either when 2D estimated or 3D (2D-VC-average: 5.3 ± 2.8 mm in A-FTR vs 6.6 ± 3.7 in V-FTR. P= 0.02; 3D-VCA: 0.9 ± 0.4 cm2 vs 1.3 ± 1.1 cm2 p= 0.02); conversely the value of 2D-ERO and regurgitant volume estimated with 2D-PISA method did not show significant difference between the 2 groups (table 1). After a median follow-up of 24 months (IQR: 2-48) 72 patients (40%) reached the primary end-point and 64 (36%) hospitalized for HF. Different predictors of combined end point were found in the 2 groups: tenting height. 2D-VC. 3D-VCA and regurgitant fraction were prognostic correlates in V-FTR; TA dimensions as well as all the parameters of severe TR. including EROA with PISA method were related to the prognosis in A-FTR (table 2). Conclusions Prognostic role of quantitative parameters of FTR in A-FTR and V-FTR is different, thus reaffirming the difference in underlying pathogenic mechanisms and the needing for a more specific diagnostic approach and prognostic stratification in these two FTR phenotypes

145 Prognostic value of three-dimensional echocardiographic assessment of tricuspid valve geometry in atrial and ventricular functional tricuspid regurgitation

Abstract Aims Atrial and ventricular functional tricuspid regurgitation (A-FTR and V-FTR) have recently emerged as different phenotypes of FTR. Given the difference in mechanisms that are postulated to be underlying these two entities, a different remodelling of tricuspid valve (TV) apparatus can occur and therefore also a specific quantitative approach could be deemed. Moreover, considered the known limitation of the two-dimensional flow convergence method (2D-PISA) for quantifying FTR in advanced valve apparatus remodelling with irregular effective valve orifice (ERO) morphology, it would be expected that also the parameters of severity of FTR can be different in these two types of FTR. The aim of this study was to investigate the TV apparatus remodelling in the two different phenotypes of FTR: ventricular (V-FTR) and atrial (A-FTR) and the role of echocardiographic parameters of TV remodelling and TR severity to predict clinical outcomes. Methods and results The present retrospective study included consecutive patients with moderate to severe functional tricuspid regurgitation (FTR) referred for echocardiography in two Italian centres. The composite endpoint of death for any cause and heart failure (HF) hospitalization was used as primary outcome of this analysis. According to more recent guidelines, patients were considered having A-FTR if having history of long-standing atrial fibrillation, without history of pulmonary hypertension and left side heart disease. A total of 180 patients were included. Despite the right atrial volume (RAV) was not different in the two groups, in A-FTR tethering height was significantly lower (11.7 ± 4.8 mm vs. 15.0 ± 5.5 in V-FTR. P &amp;lt; 0.01) and the 3D-derived tricuspid annulus (TA) diameters were larger both in end-diastolic and mid-systolic phase (3D-TA-End diastolic-major axis: 45.2 ± 6.2 mm in A-FTR vs. 42.8 ± 5.4 in V-FTR. P = 0.04; 3D-TA mid systolic major axis: 41.7 ± 6.4 mm in A-FTR vs. 37.9 ± 5.1 in V-FTR, P &amp;lt; 0.01). 3D-TA-End diastolic-minor axis: 39.7 ± 6.8 vs. 37.1 ± 5.2. P = 0.03. Regarding the parameters of severity of FTR, patients with V-FTR had larger vena contracta (VC), either when 2D estimated or 3D (2D-VC-average: 5.3 ± 2.8 mm in A-FTR vs. 6.6 ± 3.7 in V-FTR. P = 0.02; 3D-VCA: 0.9 ± 0.4 cm2 vs. 1.3 ± 1.1 cm2, P = 0.02); conversely the value of 2D-ERO and regurgitant volume estimated with 2D-PISA method did not show significant difference between the two groups. After a median follow-up of 24 months (IQR: 2–48) 72 patients (40%) reached the primary endpoint and 64 (36%) hospitalized for HF. Different predictors of combined endpoint were found in the two groups: tenting height. 2D-VC. 3D-VCA and regurgitant fraction were prognostic correlates in V-FTR; TA dimensions as well as all the parameters of severe TR, including EROA with PISA method were related to the prognosis in A-FTR. Conclusions Different TV remodelling occurs in patients with A- and V-FTR, having the second more pronounce tethering of TV leaflets; the prognostic role of quantitative parameters of FTR in these two groups is different, thus reaffirming: (1) the limitation of PISA method without correction in case of more pronounced tenting of leaflets; (2) the difference in underlying pathogenic mechanisms; and (3) the needing for a more specific diagnostic approach and prognostic stratification in these two FTR phenotypes.

Tricuspid annular abnormalities in repaired dextro-transposition of the great arteries following Senning and Mustard procedures (Insights from the CSONGRAD Registry and MAGYAR-Path Study).

In dextro-transposition of the great arteries (dTGA), the aorta and the pulmonary artery are transposed in position, when aorta arises from the right ventricle and pulmonary artery arises from the left ventricle. The present study was designed to assess three-dimensional speckle-tracking echocardiography-derived tricuspid annular (TA) abnormalities in adult patients with dTGA late after atrial switch operations. It was also examined whether differences in TA morphology and function exist between Senning- and Mustard-procedures. The study consisted of 14 adult dTGA patients (mean age: 29.9±8.3 years, 6 males), who underwent Mustard-procedure (n=7) at the age of 1.57±0.53 years or Senning-procedure (n=7) at the age of 1.42±0.53 years. Their results were compared to 28 age- and gender-matched healthy subjects (30.3±4.9 years, 14 males). Dilated end-systolic and end-diastolic TA diameters, areas and perimeters could be detected in dTGA patients as compared to those of controls. TA functional properties calculated from TA diameter (TAFS) and area (TAFAC) data proved to be deteriorated in dTGA patients. No differences could be detected either in TA dimensions, or in TA functional properties between Senning- and Mustard-operated dTGA patients. TA plane systolic excursion (TAPSE) was reduced, which did not correlate with TAFAC and TAFS in dTGA patients. In dTGA, dilated end-systolic and end-diastolic TA is accompanied with deteriorated TA functional properties regardless of which atrial switch procedure was performed. Correlations between TAPSE representing longitudinal movement of the TA and TAFAC and TAFS representing sphincter-like movement of the TA disappeared, which could partially explain accompanying tricuspid functional regurgitations. Tricuspid annulus; function; three-dimensional echocardiography; speckle-tracking; transposition of the great arteries.

Tricuspid annular abnormalities following different surgical strategies in adults with corrected tetralogy of Fallot (Results from the CSONGRAD Registry and MAGYAR-Path Study).

Although there is an increasing number of patients with corrected tetralogy of Fallot (cTOF), who reach adulthood due to recent successful surgical procedures, some of them suffers from late complications, including functional tricuspid regurgitation (FTR). The purpose of the present study was to examine tricuspid annular (TA) abnormalities in adult cTOF patients and their relationship right atrial (RA) volumes respecting the cardiac cycle assessed by three-dimensional speckle-tracking echocardiography (3DSTE). Moreover, the effect of different surgical procedures on TA morphologic and functional parameters was examined as well. The study comprised 24 cTOF patients (32.8±13.5 years, 9 males) in which early palliative surgery and late total correction were performed in 12 cases (pcTOF), while early total reconstruction was performed in 12 subjects (etrTOF). Their results were compared to those of 33 matched healthy adults (36.7±7.2 years, 15 males). Dilated end-systolic and end-diastolic TA morphologic parameters and their body surface area-indexed counterpart could be detected in cTOF patients as compared to that of controls. TA fractional area change and TA fractional shortening proved to be reduced in cTOF patients as well as in etrTOF and pcTOF patients compared to controls. None of the TA morphologic and functional parameters showed any differences between etrTOF and pcTOF patients. Increased maximum, preatrial contraction and minimum RA volumes could be detected in cTOF patients compared to controls, which correlated with TA dimensions. TA is dilated with reduced function in adult patients with cTOF. TA dilation is related to RA volumes. etrTOF and pcTOF patients have similar TA dimensions and TA functional properties. Fallot; tricuspid annulus; three-dimensional (3D); speckle-tracking; echocardiography.