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JACC: CARDIOVASCULAR IMAGING
VOL. 7, NO. 12, 2014
ª 2014 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION
ISSN 1936-878X/$36.00
PUBLISHED BY ELSEVIER INC.
http://dx.doi.org/10.1016/j.jcmg.2014.08.008
EDITORIAL COMMENT
Severe Tricuspid Valve Regurgitation Is
Not an Innocent Finding to Be Ignored!*
Gösta B. Pettersson, MD, PHD,y L. Leonardo Rodriguez, MD,z Eugene H. Blackstone, MDyx
I
n this issue of iJACC, Topilsky et al. (1) at
echocardiographic variables collected from patients
the Mayo Clinic present a provocative study on
with more severe TR, including estimation of RV sys-
the clinical outcome of isolated tricuspid regur-
tolic pressure as a surrogate for pulmonary artery
gitation (TR). These authors studied the late out-
pressure.
comes of patients with isolated TR collected in a
The results of this study show that of several
program of TR quantification that enrolled patients
measures collected from 1 clinical and 1 echocardio-
with holosystolic TR from 1995 to 2005. In this study,
graphic examination, TR quantification by regur-
isolated TR included patients with no other important
gitant orifice area (PISA) was the most predictive of
valvular or other cardiac disease, but included pa-
adverse outcomes. Although the visual qualitative
tients with atrial fibrillation and elevated right ven-
estimation of TR severity was useful to identify the
tricular (RV) systolic pressure to <50 mm Hg. All
highest risk patients, it was less predictive of out-
underwent a comprehensive echocardiographic study
comes. Some aspects of the evaluation are note-
of cardiac morphology and function, including TR
SEE PAGE 1185
worthy. Several modifications of the PISA method
were made that are not routinely used in daily clinical
practice (2) and not included in American Society of
quantification using the proximal isovelocity surface
Echocardiography guidelines (3). RV function was
area (PISA) method. After exclusion of patients with
evaluated qualitatively and by indexes of myocardial
pulmonary hypertension, overt cause of TR, or a
performance (right ventricular index of myocardial
serious life-limiting illness, 142 patients with isolated
performance or myocardial performance index), but
functional TR were identified: 74 with mild to moder-
the investigators did not re-review the echocardio-
ate TR and 68 with severe TR. To address the authors’
grams to measure “more recent methods” of RV
objective to study the effect of isolated (functional)
assessment, such as tricuspid annular plane systolic
TR on outcomes compared with those of patients hav-
excursion, lateral annular systolic velocity, and strain
ing trivial TR, 1,972 patients with trivial TR were iden-
and strain rate.
tified during the same period, and from this group, 211
After the index echocardiographic examination,
were selected for the study by frequency (not propen-
the primary authors appear not to have been further
sity) matching to 5 variables: sex, age within 10 years,
involved in managing the patients; rather, patients
left ventricular (presumably) ejection fraction within
returned to and were treated and followed by other
5%, year of diagnosis, and the presence or absence
physicians. Indications for this referral are not
of atrial fibrillation. Selecting patients with trivial
provided, and we therefore presume that these pa-
(rather than no) TR allowed collection of the same
tients had a clinical indication for their referral to
undergo echocardiography. We do not know how
*Editorials published in JACC: Cardiovascular Imaging reflect the views of
the authors and do not necessarily represent the views of JACC:
Cardiovascular Imaging or the American College of Cardiology.
From the yDepartment of Thoracic and Cardiovascular Surgery, Heart and
Vascular Institute, Cleveland Clinic, Cleveland, Ohio; zDepartment of
Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic,
Cleveland, Ohio; and the xDepartment of Quantitative Health Sciences,
Research Institute, Cleveland Clinic, Cleveland, Ohio. The authors have
many were symptomatic, only that symptoms were
more frequent in those with more than trivial TR.
Atrial fibrillation was present in 45% of patients
with trivial TR and 44% of those with mild to
severe TR.
Outcomes were assessed by review of medical records, follow-up surveys, and telephone interviews.
reported that they have no relationships relevant to the contents of
Endpoints were all-cause mortality and cardiovascu-
this paper to disclose.
lar events (cardiac deaths, including sudden death
1196
Pettersson et al.
JACC: CARDIOVASCULAR IMAGING, VOL. 7, NO. 12, 2014
DECEMBER 2014:1195–7
Editorial Comment
and death caused by congestive heart failure). Out-
That only 12 of 68 patients (18%) with severe TR
comes were analyzed from echocardiographic diag-
underwent surgery becomes disturbing in light of
nosis until death, cardiac surgery, or last follow-up up
<40% 10-year survival and suggests that a more
to 2010. We must presume the follow-up was 100%
aggressive approach is justified. Presentation of a
complete unless inability to determine outcome was
competing risks curve for death and surgery would be
another exclusion criterion.
helpful. It would also be instructive to know how
This is a timely paper, further fueling the debate
congestive heart failure was handled: Were patients
surrounding the clinical importance of TR and RV
censored after 1 episode? More careful follow-up
dysfunction and an increasingly aggressive approach
studies are needed to provide more data points for
to severe TR. Some even suggest tricuspid annulo-
clinical symptomatology, TR development, tricuspid
plasty based only on the diameter of the tricuspid
valve tethering, RV morphology, function, and he-
annulus in patients undergoing surgery for left-sided
modynamics, and studies of effectiveness and dura-
heart disease with the potential for developing func-
bility of tricuspid valve surgery with regard to these
tional TR (4). In our studies of functional TR sec-
echocardiographic variables to finalize our conclusion
ondary to degenerative mitral valve disease, TR went
that isolated severe TR is a surgical disease and to
hand in hand with RV dysfunction, which was prog-
recommend revising surgical guidelines. Today, the
nostically more important than TR (5,6).
American Heart Association/American College of
In our practice, symptomatic patients with severe
Cardiology guidelines deem primary TR unresponsive
TR, with or without atrial fibrillation, undergo a series
to medical therapy as a class IIa recommendation for
of studies, including special echocardiographic mea-
surgery (7). We have provided data about the efficacy
sures of RV function, magnetic resonance imaging,
of tricuspid valve repair for functional TR in patients
and right and left heart catheterization, all of which
with degenerative mitral valve disease; in these pa-
are clinically integrated. Patients are considered for
tients, tricuspid valve repair seems to effectively and
tricuspid valve surgery if RV function is deemed good
durably eliminate TR and improve RV function,
enough for the heart to take advantage of a compe-
whereas mitral valve surgery alone accomplishes only
tent tricuspid valve. We would carefully look for and
a temporary improvement (8).
consider any possible cause of TR, be it functional
To us, the right side of the heart is humbling. It is
with a possible forward cause of TR (left-sided heart
less well studied and understood than the left. This
disease with pulmonary venous hypertension, pul-
includes the interaction between RV morphology and
monary disease with increased pulmonary vascular
function and TR, right/left ventricular interaction,
resistance, pulmonary valve disease, or intrinsic RV
clinical importance of TR, indications for surgery,
disease), intrinsic structural tricuspid valve disease,
surgical techniques for tricuspid valve repair, and
or functional tricuspid valve disease with a possible
postoperative management. The search for new ways
cause from the right atrial side (atrial fibrillation or
to repair valves with functional TR is an indication of
left-to-right shunts [atrial septal defect]). Any such
the limitations of our present techniques and our
cause would be weighed and in principle strengthen
understanding of the tricuspid valve. The authors
the indication for surgery. Because atrial fibrillation is
represent the echocardiography laboratory with the
a possible cause of TR, we would not categorize TR as
greatest confidence in the PISA technique and should
isolated in such a patient. After this diagnostic
be congratulated on this powerful study. The next
workup, our group of patients with isolated func-
and important step will be to gain further insight into
tional TR would be very small! However, whether the
the roles of RV function and hemodynamics in
authors are right in their use of the “concept of
informing our management of patients with TR.
functional isolated TR” or they are just studying patients with “isolated TR” is unimportant. The study
REPRINT REQUESTS AND CORRESPONDENCE: Dr.
does not claim to add to our mechanistic under-
Gösta B. Pettersson, Department of Thoracic and
standing of isolated TR. Rather, the fact that 1 clinical
Cardiovascular Surgery, Cleveland Clinic, 9500 Euclid
assessment and 1 echocardiogram are this prognosti-
Avenue, Desk J4-1, Cleveland, Ohio 44195. E-mail:
cally predictive makes this paper powerful.
[email protected].
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DECEMBER 2014:1195–7
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Ann Thorac Surg 2005;79:127–32.
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Editorial Comment
functional tricuspid regurgitation accompanying
mitral valve disease. J Thorac Cardiovasc Surg
2013;145:1234–41.
on Practice Guidelines. J Am Coll Cardiol 2014;
63:2438–88 (erratum in J Am Coll Cardiol 2014;
63:2489).
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of right ventricular morphology and function on
outcomes of patients with degenerative mitral
8. Desai RR, Vargas Abello LM, et al. Tricuspid
regurgitation and right ventricular function after
mitral valve surgery with or without concomitant
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Cardiology/American Heart Association Task Force
KEY WORDS effective regurgitant orifice,
isolated tricuspid regurgitation, prognosis,
tricuspid regurgitation
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