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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]. REFERENCES 1. Topilsky Y, Nkomo VT, Vatury O, et al. Clinical outcome of isolated tricuspid regurgitation. J Am Coll Cardiol Img 2014;7:1185–94. 2. Rodriguez L, Anconina J, Flachskampf FA, Weyman AE, Levine RA, Thomas JD. Impact of finite orifice size on proximal flow convergence. Implications for Doppler quantification of valvular regurgitation. Circ Res 1992;70: 923–30. Pettersson et al. JACC: CARDIOVASCULAR IMAGING, VOL. 7, NO. 12, 2014 DECEMBER 2014:1195–7 3. Zoghbi WA, Enriquez-Sarano M, Foster E, Grayburn PA, Kraft CD, Levine RA, et al. American Society of Echocardiography. Recommendations for evaluation of the severity of native valvular regurgitation with two-dimensional and Doppler echocardiography. J Am Soc Echocardiogr 2003; 16:780–1. 4. Dreyfus GD, Corbi PJ, Chan KM, Bahrami T. Secondary tricuspid regurgitation or dilatation: which should be the criteria for surgical repair? Ann Thorac Surg 2005;79:127–32. 5. Vargas-Abello LM, Klein AL, Marwick TH, et al. Understanding right ventricular dysfunction and 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). 6. Ye Y, Desai R, Vargas-Abello LM, et al. Effects 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 valve disease. J Thorac Cardiovasc Surg 2014 Mar 1 [E-pub ahead of print]. tricuspid valve procedure. J Thorac Cardiovasc Surg 2013;146:1126–32. 7. Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: executive summary: a report of the American College of Cardiology/American Heart Association Task Force KEY WORDS effective regurgitant orifice, isolated tricuspid regurgitation, prognosis, tricuspid regurgitation 1197