Tricuspid Valve Apparatus Research Articles

Prognostic Value of Tricuspid Valve Geometry and Leaflet Coaptation Status in Patients Undergoing Tricuspid Annuloplasty: A Three-Dimensional Echocardiography Study

The advent of three-dimensional echocardiography (3DE) enables detailed evaluation of the tricuspid valve (TV) apparatus; nonetheless, the clinical value of preoperative 3DE is unknown in patients undergoing tricuspid annuloplasty (TA). The aim of this study was to evaluate the prognostic value of TV geometric parameters and leaflet coaptation status evaluated by 3DE in patients undergoing TA. A total of 122 patients who underwent TA during left-sided heart valve surgery were prospectively evaluated. Detailed 3DE was performed before surgery. Adverse outcome was defined as the occurrence of heart failure requiring hospital admission or all-cause mortality following TA. A total of 33 adverse events (17 heart failures and 16 deaths) occurred during a median follow-up of 36months. Tethering volume (hazard ratio=1.32; 95% CI=1.05-1.66; P=.01) and ratio of total leaflet length to closure length (hazard ratio=1.07; 95% CI=1.03-1.12; P<.01) were associated with adverse events after adjustment for age, sex, and tricuspid regurgitation vena contracta width. Receiver-operator characteristic curve analysis revealed that tethering volume (area under curve=0.73) and ratio of total leaflet length to closure length (area under curve=0.75) were most associated with adverse events at 1-year follow-up. The presence of either a large tethering volume or a low ratio of total leaflet length to closure length was predictive of an adverse outcome 1year following TA. Our study suggests that 3DE-derived TV tethering volume and ratio of total leaflet length to closure length are important preoperative measures associated with adverse events in patients undergoing TA.

Predictors and Outcomes of Persistent Tricuspid Regurgitation After Transcatheter Aortic Valve Implantation

Persistent tricuspid regurgitation (TR) after transcatheter aortic valve implantation (TAVI) has been reported to increase mortality. The aim of this study was to investigate clinical and echocardiographic determinants and outcome of persistent TR after TAVI. We reviewed 1,085 patients who underwent TAVI. Among them, 100 patients who had ≥moderate TR without organic dysfunction of the tricuspid valve apparatus were studied. Preprocedural and follow-up transthoracic echocardiography after TAVI were analyzed. After TAVI, patients were divided into persistent TR group and improved TR group. Clinical event was defined as all-cause mortality and readmission for heart failure within 1,000 days. Fifty-three (53%) patients had persistent TR, whereas 47 (47%) patients had improved TR. Risk of clinical event was significantly higher in the persistent TR group compared with the improved TR group. Atrial fibrillation (AF) and tricuspid annular dimension (TAD; p <0.05 for all) were independent predictors of persistent TR. Receiver operating characteristic curve showed the optimal cut-off value of TAD for predicting persistent TR was 37 mm. The combination of AF and TAD ≥37 mm was associated with persistent TR (p <0.001). In conclusion, AF and dilated TAD before TAVI predicted persistent TR which was associated with higher all-cause mortality and readmission for heart failure.

Mechanics of the Tricuspid Valve-From Clinical Diagnosis/Treatment, In-Vivo and In-Vitro Investigations, to Patient-Specific Biomechanical Modeling.

Proper tricuspid valve (TV) function is essential to unidirectional blood flow through the right side of the heart. Alterations to the tricuspid valvular components, such as the TV annulus, may lead to functional tricuspid regurgitation (FTR), where the valve is unable to prevent undesired backflow of blood from the right ventricle into the right atrium during systole. Various treatment options are currently available for FTR; however, research for the tricuspid heart valve, functional tricuspid regurgitation, and the relevant treatment methodologies are limited due to the pervasive expectation among cardiac surgeons and cardiologists that FTR will naturally regress after repair of left-sided heart valve lesions. Recent studies have focused on (i) understanding the function of the TV and the initiation or progression of FTR using both in-vivo and in-vitro methods, (ii) quantifying the biomechanical properties of the tricuspid valve apparatus as well as its surrounding heart tissue, and (iii) performing computational modeling of the TV to provide new insight into its biomechanical and physiological function. This review paper focuses on these advances and summarizes recent research relevant to the TV within the scope of FTR. Moreover, this review also provides future perspectives and extensions critical to enhancing the current understanding of the functioning and remodeling tricuspid valve in both the healthy and pathophysiological states.

Anatomic Relationship of the Complex Tricuspid Valve, Right Ventricle, and Pulmonary Vasculature

Severe functional or secondary tricuspid regurgitation (TR) is associated with poor long-term outcomes in natural history studies as well as specific disease states. An understanding of the physiologic causes of the TR is lacking precluding a systematic approach to treatment. The complex anatomic relationship between the tricuspid valve apparatus and structure of the right side of the heart lends insight into the functional changes seen with secondary TR. The association of these changes with changes in pulmonary vascular hemodynamics can lead to a cascade of events that result in disease progression. Appreciating the role of pulmonary vascular hemodynamics on right ventricular and tricuspid valve morphology and function improves our understanding of the pathophysiology of secondary TR. The limitations of current therapeutic approaches for secondary TR have stimulated interest in improving outcomes with this morbid disease. Changes in timing or approach to intervention require a more comprehensive understanding of the pathophysiology.

Early failure of tricuspid annuloplasty. Should we repair the tricuspid valve at an earlier stage? The role of right ventricle and tricuspid apparatus.

We sought to identify subgroups of patients at a higher probability of tricuspid annuloplasty (TAP) failure early after surgery. From May 2009 to December 2015, 688 patients undergoing TAP for functional tricuspid regurgitation (FTR) at a single institution were included in the study. In all patients, a complete transthoracic echocardiographic evaluation of right ventricle (RV) and tricuspid valve (TV) apparatus was collected. Twenty-six patients (3.8%) died within the first 30 days of surgery. Residual TR after TAP was recorded in 85 (12.4%), moderate in 80 (11.7%) and severe in 5 (0.7%). Preoperative TV apparatus remodeling was associated with residual TR; in particular, the following cutoffs were identified: TV coaptation depth ≥6.5 mm, tenting area ≥0.85 cm2 , and tricuspid annulus ≥35 mm. The entire cohort was stratified in three subsets: patients having preoperative mild/moderate TR without preoperative TV apparatus and/or RV remodeling (n = 178); patients having mild/moderate TR with TV apparatus and/or RV remodeling (n = 317); patients with severe TR regardless of TV apparatus and/or RV remodeling (n = 193). Residual TR was 2.8%, 10.4%, and 24.3%, respectively (P < 0.001). At multivariable analysis, patients showing preoperative mild/moderate TR with TV apparatus and/or RV remodeling as well as patients with severe TR were at significantly higher risk for early failure. No difference was found regarding the type of TV repair performed. Prophylactic TAP should be encouraged among surgeons even earlier than guidelines recommend, and decision-making for the treatment of low-grade FTR at the time of left-sided valve surgery should take into consideration not only annular size but also tethering severity and RV dilatation.

OC28 FAILURE OF TRICUSPID ANNULOPLASTY FOR FUNCTIONAL TRICUSPID REGURGITATION. THE ROLE OF PREOPERATIVE TRICUSPID VALVE APPARATUS REMODELING

Background: To identify the determinants of both early and late tricuspid annuloplasty (TAP) failure. Methods: From May 2009 to December 2015, 688 patients undergoing TAP for functional tricuspid regurgitation (TR) at a single institution were included in the study. Inclusion criteria: MV disease requiring surgical intervention; no pathologic changes in TV leaflets; no previous TV repair; not requiring associated tricuspid valvuloplasty. In 423 patients, echocardiographic evaluation was performed both at discharge and after a median of 35 (22–58) months. Residual and Recurrence TR were defined as TR higher than mild. Logistic regression and Cox analysis were used as multivariable model for early and late failure. ROC curve was used to identify cutoffs Results: Residual TR after TAP was recorded in 54 (13%); Risk factors for residual TR were: preoperative severe TR regardless of tricuspid valve (TV) apparatus remodeling, mild or moderate TR in presence of TV apparatus remodeling, defined as coaptation depth ≥6.5 mm (sensitivity 55%; specificity 80%), tenting area ≥0.85 cm2 (52%; 75%), and tricuspid annulus ≥40 mm (60%; 72%). Recurrent TR was recorded in 85 (20%) cases, Five-year freedom from TR recurrence was 74.0 ± 3.0%. The following risk factors for recurrent TR were identified: residual TR (Figure), atrial fibrillation at follow-up, mild/ moderate TR with TV apparatus remodeling, severe TR. Conclusions: Prophylactic TAP should be encouraged among surgeons even earlier than guidelines recommend. Decision-making for the treatment of low-grade FTR at the time of left-sided valve surgery should take into consideration not only annular size, but also tethering severity.

Tricuspid Regurgitation - Medical Management and Evolving Interventional Concepts.

Severe tricuspid regurgitation (TR) is a complex condition of the right ventricle (RV) and tricuspid valve apparatus and is frequently associated with symptomatic heart failure and a significant morbidity and mortality. In these patients, left heart pathologies lead to chronic pressure overload of the RV, eventually causing progressive RV dilatation and functional TR. Therefore, TR cannot be considered as isolated heart valve disease pathology but has to be understood and treated as one component of a complex structural RV pathology and is frequently also a marker of an advanced stage of cardiac disease. In these patients, medical therapy restricted to diuretics and heart failure medication is frequently ineffective. Also, severe TR in the setting of advanced heart failure constitutes a high risk for cardiac surgery. Neither one of these treatment options has demonstrated a beneficial effect on long-term prognosis. The recent innovations in transcatheter technology led to efforts to develop interventional approaches to severe TR. Multiple innovative treatment concepts are currently under preclinical and clinical investigation to replace or repair TV function. However, up to date none of these approaches is established and there is still a lack of clinical data to support the efficacy of transcatheter TR treatment.

First Description of Tricuspid Valve Dysplasia in a Basset Hound

This report represents the first description of tricuspid valve dysplasia in a Basset hound. We evaluated clinical signs, ECG abnormalities and echocardiographic findings related to tricuspid valve dysplasia in a 6 month Basset Hound. A specific protocol of cardiologic examination was performed every time the patient was evaluated. This protocol included: clinical exam, ECG and echocardiographic investigation. The clinical examination identified over the entire period of surveillance a dog with good body condition score (2.5-3/5), alert, bright, being able to take moderate exercise. A 4/6 left heart base systolic murmur was identified at every examination. ECG revealed a sinus rhythm. Echocardiography identified right heart abnormality, with malposition of tricuspid annulus, one leaflet being short and thick and other extremely long with abnormal motion. Due to abnormal morphology of tricuspid valve apparatus a tricuspid regurgitant jet was noted with Color Doppler. The left heart seemed to have normal morphology. An atrial septal defect was also noticed. Further studies need be performed in order to establish if tricuspid valve dysplasia in Basset hound is a congenital or genetic defect.

Tricuspid valve imaging.

The right ventricle and tricuspid valve (TV) have long been neglected by cardiologists. Functional tricuspid regurgitation (TR) is nowadays the most common cause of severe TR and is emerging as a prognostic factor in many heart diseases. A multimodality imaging approach is fundamental for defining the pathophysiology of TR, using both two-dimensional and three-dimensional echocardiography, as well as CT scan. In particular, 3D echocardiography can characterize TV apparatus and tricuspid annulus; CT offers complementary information about annular structure, and its relationship with the right coronary artery. The following review will describe TV anatomy, define transthoracic and transesophageal echocardiographic views for evaluating TV morphology, function and TR grading with some clues on interventional perspectives.

ENTRAPMENT OF LASSO CATHETER IN CHIARI NETWORK: SUCCESSFUL EXTRACTION

Lasso catheter (LC) is commonly used for multiple electrode electrophysiological mapping of cardiac structures. Its entrapment has been reported in the mitral valve and tricuspid valve apparatus. A 57-year-old man with history of persistent atrial fibrillation (failed Dofetilide therapy) and

Experimental Study of Right Ventricular Hemodynamics After Tricuspid Valve Replacement Therapies to Treat Tricuspid Regurgitation.

The increased understanding of right heart diseases has led to more aggressive interventions to manage functional tricuspid regurgitation (FTR). In some cases of FTR, prosthetic valve replacement is typically considered when concomitant organic components or significant geometrical distortions are involved in the pathology of the tricuspid valve. However, little is known of the performance of current devices in the right heart circulation. In this study, a novel in vitro mock circulatory system that incorporated a realistic tricuspid valve apparatus in a patient-specific silicon right ventricle (RV) was designed and fabricated. The system was calibrated to emulate severe FTR, enabling the investigation of RV hemodynamics in pre- and post-implantation of tri-leaflet tissue implant and bi-leaflet mechanical implant. 2D particle imaging velocimetry was performed to visualize flow and quantify relevant hemodynamic parameters. While our results showed all prosthetic implants improved cardiac output, these implants also subjected the RV to increased turbulence level. Our study also revealed that the implants did not create the optimal behavior of fluid transfer in the RV as we expected. Among the implants tested, tissue implant created the most dominant vortices, which persisted throughout diastole; its observed strong negative vortex could lead to increase energy expenditure due to undesired fluid direction. In contrast, both native valve and mechanical implant had both weaker vortex formation as well as more significant vortex dissipation. Interestingly, the vortex dissipation of native valve was associated with streamlined flow pattern that tended towards the pulmonary outlet, while the mechanical implant generated more regions of flow stagnation within the RV. These findings heighten the imperative to improve designs of current heart valves to be used in the right circulation.

Emerging Transcatheter Options for Tricuspid Regurgitation.

Tricuspid regurgitation (TR) presents as either primary valve pathology or secondary to pulmonary or left-sided heart disease. Severe TR portends a worse prognosis independent of age, right ventricular size and function, severe left ventricular dysfunction, and increased pulmonary arterial pressures. Surgical treatment for TR has mostly been limited to patients undergoing mitral valve repair since those at high surgical risk are not candidates for traditional TR surgery. For these patients, minimally invasive techniques could be of great benefit, yet these techniques have been slow to develop because of the various anatomic and physiological aspects of the tricuspid valve apparatus. Several promising new techniques are currently undergoing clinical investigation, including caval valve implantation, percutaneous tricuspid annuloplasty techniques (Trialign, TriCinch, Cardioband), edge-to-edge repair with the MitraClip system, the FORMA device, and the GATE tricuspid Atrioventricular Valved Stent. Further evaluation of their safety and long-term efficacy is warranted prior to commercial approval and widespread adoption.

Transthoracic Three-Dimensional Echocardiography of Tricuspid Valve

Imaging of the tricuspid valve (TV) by three-dimensional echocardiography (3DE) has not received much attention. 3DE allows users to visualize the whole TV apparatus from any perspective and enables a comprehensive evaluation of the leaflets. This review summarizes the current status of real time 3DE evaluation of TV morphology and function with its potential implications for TV disease assessment, as well as its clinical applications and limitations.

P1246Age-, body size-, and sex-specific reference values for tricuspid valve apparatus parameters by real-time three-dimensional transthoracic echocardiographyP1247Surgical therapy in infective endocarditis: predisposing and prognostic factorsP1248Evalutation of MV annulus geometry modifications before and after mitraclip implantation with 3D transesophageal echocardiographyP1249Prognostic echocardiographic parameters for successful transcatheter edge-to-edge mitral valve repairP1250Influence of body surface area in diagnosis and outcome patient-prosthesis mismatch after TAVI.

and Purpose-Tricuspid valve (TV) apparatus parameters can vary significantly with demographic and anthropometric factors and could be useful for clinical decision making. Our aim was to (1) establish the reference values for TV apparatus parameters using transthoracic three-dimensional (3D) echocardiography; (2) investigate the influence of age, sex, and body size on TV anatomy.

Hypertrophic Cardiomyopathy and Tricuspid Regurgitation with Right Heart Failure Mimicking Constrictive Pericarditis: A Rare Case Report

Cardiomyopathy is the measurable deterioration of the function of the myocardium for any reason, usually leading to heart failure. Tricuspid regurgitation may result from structural alterations of any one or all of the components of the tricuspid valve apparatus which include the leaflets, chordae tendinae, annulus, and papillary muscles or adjacent right ventricular muscle. We are reporting a case of Cardiomyopathy with tricuspid regurgitation with right heart failure in a 38 years male. Preoperatively he was diagnosed as a case of constrictive pericarditis. Diagnosis of Tricuspid regurgitation with cardiomegaly was confirmed peroperatively. During operatrion tricuspid valve anatomy dimunited and severe tricuspid regurgitation was identified. Grossly dilated RA, RV identified and other anatomy of heart was normal. De-Vega Tricuspid anuloplasty done with pledgeted stich 2-0 polyster. Part of right atrial wall (2X2.5 inch) excised and resected portion sent for histopathology. Postoperative course was uneventful with marked improvement of symptoms.University Heart Journal Vol. 11, No. 1, January 2015; 45-47

The long-term impact of various techniques for tricuspid repair in Ebstein's anomaly

ObjectiveWe describe a repertoire of repair techniques according to type of Ebstein's anomaly to correct tricuspid valve (TV) incompetence, and report long-term ventricular function and functional outcomes. MethodsSixty-eight patients (mean age, 26.9 ± 7.3 years) with Ebstein's anomaly (type A, n = 21; type B, n = 23; type C, n = 15; type D, n = 9) underwent correction of TV incompetence under normothermic cardiopulmonary bypass. The atrialized ventricle, TV, and subvalvar apparatus were inspected to analyze the precise morphology and determine which leaflet was the most mobile. Various repair strategies (anterior and/or posterior annulorrhapy, Sebening stitich, double-orifice valve technique, with bidirectional Glenn anastomosis if necessary) were used according to the presenting morphology and applied according to the type of Ebstein's anomaly. In all, the atrialized right ventricle (RV) was incorporated into the contractile RV by partial closure of the natural annulus using the most mobile leaflet for valve competence. ResultsThe mean duration of follow-up was 13.25 ± 1.3 years (median, 9.34 years; range, 1-24 years). The mean New York Heart Association class improved from 3.4 to 1.3 (P < .001). The mean severity of TV incompetence was reduced from 3.2 to 1.3 (P < .001). Exercise tolerance tests demonstrated improved maximal oxygen uptake from a mean of 15 ± 7.8 ng/kg/min preoperatively to a mean of 24.9 ± 2.0 ng/kg/min postoperatively (P < .02). Displacement tissue Doppler imaging was used to evaluate overall cardiac performance of the RV and left ventricle and interventricular septum. The mean basal, middle, and apical ventricular strain improved significantly from preoperative values of 18.08%, 15.6%, and 13.9%, respectively to postoperative values of 25.7% (P < .011), 23.7% (P < .001), and 19.36% (P < .05), respectively. Freedom from reoperation was 100% at 1 year, 98.3% at 5 years, and 92.9% at 20 years. Early mortality was 2.9%, and late mortality was 5.8%. The overall survival rate was 97.6% at 30 days, 92.7% at 5 years, and 91.26% at 20 years. ConclusionsThe various repair techniques, all of which preserve the atrialized chamber and are used individually according to morphology, provide satisfactory long-term ventricular function and functional outcome even in severe types of Ebstein's anomaly.

PP-114 Relationship between the Frequency of Idiopathic Ventricular Premature Beats and Transmural Dispersion of Repolarization Parameters

TS was detected during routine follow-up. TTE and TEE examinations revealed thickened tricuspid valve leaflets and subvalvular apparatus and a mean diastolic gradient of 7 mmHg across the tricuspid valve (Figure 1). There was also mild-to-moderate tricuspid regurgitation. Since patient had no complaints specific to the tricuspid abnormality, no further intervention was planned. Conclusions: Few cases of TS were published in the literature due to cardiac pacemaker leads. In current case we assume that TS occurred after endothelial injury following repetitive trauma of mechanical lead extraction system upon tricuspid valve and subvalvular apparatus during lead extraction procedure.

Silent Embolization of an Atrial Septal Defect Occluder Into the Right Ventricle Detected 20 Months Post-Implantation

A 64-year-old woman, who had undergone transcatheter closure of a secundum-type atrial septal defect (ASD) with a 38-mm Amplatzer septal occluder (ASO) 20 months earlier, was admitted with palpitations for 1 day. She had not received routine follow-up after the procedure. Cardiac examination revealed a grade III/VI systolic ejection murmur at the left upper sternal border. Chest x-ray revealed that the ASO device was located in the right ventricular area (Fig. 1A). Immediate transthoracic echocardiography confirmed that the ASO device had become dislodged and embolized into the right ventricle. The embolized device was oriented in the longitudinal plane, parallel to the direction of blood flow across the tricuspid valve (Fig. 1B). Although the patient remained hemodynamically stable, she was referred for urgent surgical retrieval of the device and closure of the defect. In surgery, the embolized occluder was identified in the right ventricular inflow tract and appeared to be firmly adhering to the tricuspid valve apparatus (Fig. 1C). The inferoposterior rim of the ASD was also found to be inadequate. The endothelialization status of the retrieved device revealed that embolization must have occurred months earlier (Fig. 1D). The ASD was closed with a bovine pericardial patch through the right atriotomy, and the tricuspid valve was repaired with a 32-mm CosgroveEdwards annuloplasty band (Edwards Lifesciences, Irvine,

Tricuspid Valve: An Intraoperative Echocardiographic Perspective

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

Right Ventricular Mechanical Dyssynchrony and Asymmetric Contraction in Hypoplastic Heart Syndrome are Associated with Tricuspid Regurgitation

Right ventricular (RV) dysfunction and tricuspid regurgitation (TR) are associated with adverse outcome in hypoplastic left heart syndrome (HLHS) but remain poorly understood. The aim of this study was to assess RV longitudinal strain and mechanical dyssynchrony in HLHS in relation to TR. The hypothesis was that inhomogeneous RV contraction and mechanical dyssynchrony around the tricuspid valve apparatus may be associated with TR in some patients with HLHS. Echocardiograms of children aged 0 to 2 years with HLHS at all stages of surgical palliation were retrospectively reviewed for anatomic subtype and severity of TR. RV peak strain and dyssynchrony were assessed by vector velocity imaging. Sixty echocardiograms of patients with a median age of 0.54 years (interquartile range, 0.04-1.63 years) and a median weight 6.40 kg (interquartile range, 3.70-10.45 kg) demonstrated TR, which was absent or trivial in 25 (42%), mild in 20 (33%), moderate in five (8%), and severe in 10 (17%). The difference in peak longitudinal strain between the RV free wall and the septum or left-sided RV wall was significantly higher in patients with moderate or severe TR compared with no, trivial, or mild TR (2.93 ± 6.03% vs 0.16 ± 6.6%, P = .04). The difference in time to peak longitudinal strain between walls was significantly longer in moderate or severe TR compared with no, trivial, or mild TR (57.4 ± 145.1 vs 15.8 ± 75.9 msec, P = .04). There was a significant difference in anatomic subtype between patients with the most difference in peak strain compared with those with the least. RV mechanical dyssynchrony and inhomogeneous contraction are worse in patients with clinically important TR and HLHS.