Download Preoperative echocardiographic clues for the repair of

PREOPERATIVE
ECHOCARDIOGRAPHIC CLUES
FOR THE REPAIR OF TRICUSPID
VALVE AND ASSESSMENT OF
RIGHT VENTRICULAR
FUNCTIONS
Dr.Gökhan Kahveci
Secondary Tricuspid Regurgitation
 Functional or secondary tricuspid
regurgitation (STR) is the most frequent
etiology of tricuspid valve pathology
Don’t Touch
Aggressive surgical approach
Secondary Tricuspid Regurgitation
 Functional or secondary tricuspid regurgitation
(STR) refers to tricuspid regurgitation (TR)
occurring secondary to left-sided heart
disease or pulmonary hypertension in the
absence of organic lesions of the tricuspid
valve (TV) apparatus
Secondary Tricuspid Regurgitation
TR would disappear once the primary LHD had
been treated???
still influences surgical practice today
TV repair remains an all too infrequent
procedure at most surgical centers
Taramasso M-JACC-2012
STR-Prognosis
Kwak JJ ,AHJ-2008
TV Anatomy
Tricuspid orifice is
larger (6-7 cm² and
more triangular
(according to mitral
ann.)
Tricuspid
annulus has an elliptic,
nonplanar shape.
Pathophysiology of
Secondary Tricuspid Regurgitation
 Most common etiology of STR:
RV dilation and dysfunction from LHD
 The pathophysiology of STR may be divided into
3 phases:
1. Dilation of the right ventricle results in TA
dilation
2. Progressive RV and TA dilation, failure of leaflet
coaptation, and significant STR
3. Progressive RV distortion and eccentricity,
tethering of the leaflets
Secondary Tricuspid Regurgitation
 Significant tricuspid
annular dilatation is
defined by a diastolic
diameter ≥40 mm or ≥21
mm/m² in the fourchamber transthoracic
view.
 Significant tethering
coaptation distance >8 mm
ESC 2012 VHD-Guidelines
The prevalence of STR
 Degenerative mitral regurgitation
30% of
patients have TR ≥2+ at the time of mitral
surgery
 Rheumatic mitral stenosis 30% of patients
have TR ≥2+
 ischemic mitral regurgitation 30% of
patients have TR
Late TR
 Significant TR occurring late after left-heart
surgery is observed in up to 40% of patients,
with a median survival of 5 years.
 TV annuloplasty during mitral surgery results
in a lower incidence of late TR.
TR-Echocardiography
 2D Echo has the inherent limitation of not
being able to show all three tricuspid leaflets
together in the same view
 Realtime 3D Echo (RT-3DE) has the unique
capability of obtaining a short-axis plane of
the TV
TR Quantification-EACI 2013
 Normal tricuspid valve annulus diameter in
adults is 28+5 mm in the four-chamber view
(in diastole)
Average TA circumference is 78 ± 7 mm/m²
 Significant tricuspid annular dilatation is
defined by a diastolic diameter of ≥21 mm/m²
(>35 mm)
 Tenting area >1 cm² is related severe TR
TR Quantification-EACI 2013
Colour Flow Imaging
The colour flow area
of the regurgitant
jet is not
recommended to
quantify the severity
of TR.
Thecolour flow
imaging should only
be used for
diagnosing TR.
TR Quantification-EACI 2013
VC width
≥7 mm defines severe TR.
Poor accuracy of the in
eccentric jets
3D EROA >75 mm²  severe TR
(need validation)
TR Quantification-EACI 2013
Flow convergence method (PISA)
 EROA ≥40 mm² or
 RVol of ≥45 mL indicates
severe TR.
Quantitative but have several
limitations-underestimates severity
by 30%
TR Quantification-EACI 2013
 Peak tricuspid inflow
E velocity >1 m/s
suggests severe TR
 The systolic hepatic
flow reversal is
specific for severe
TR. It represents the
strongest additional
parameter for
evaluating the
severity of TR.
TR Quantification-EACI 2013
Lancellotti P-EHJ-2013
RT3DE
 The ability to visualize all
three tricuspid leaflets
simultaneously is a major
advantage of RT3DE.
 In TR patients, the
tricuspid annulus tends to
dilate in the septal-lateral
and posteroseptal-toanterolateral dimensions,
resulting in a more
circular and planar shape
compared with healthy
controls
3D-TEE
RT-3D TEE data to
describe the tricuspid
annulus.
Eccentric dilation
seen in patients with
TR.
The tricuspid
annulus shape is
complex, with
annular high and low
points, and annular
area calculation
based on linear
measurements
significantly
overestimates 3D
planimetered area
Predictors of Unsuccessful TV Repair
 Preop RV dysfunction
 Severe TR
 Severe TV tethering






Tenting area >1.63 cm²
Tenting distance >0.76 cm
Higher pulmonary artery pressures
Increased LV remodeling
Suture annuloplasty (De vega)
Larger ring size
MV replacement rather than repair
Presence of pacemaker leads
Predictors of Late TR After Mitral
Repair
Tricuspid Anulus >70 mm at the surgical table or of >40 mm or
21 mm/m² at the echo imaging
Katsi V-ICTS-2012
Dreyfus GD-Heart 2009
Echocardiography and Surgical
Technique
 Ring annuloplasty should be performed in the
presence of isolated annular dilatation.
 Conversely, when severe annular dilatation
and leaflet tethering are present, pericardial
patch augmentation of the anterior leaflet or
replacement of the TV should be considered.
ESC-2012-VHD
 Predicting the evolution of functional TR after
surgical treatment of mitral valve disease
remains difficult. Pulmonary hypertension,
increased RV pressure and dimension,
reduced RV function, AF, pacemaker leads,
and the severity of tricuspid valve
deformation (tricuspid annulus diameter,
coaptation height) are important risk factors
for persistence or late worsening of TR.
ESC2012-VHD
 Ring annuloplasty is key to surgery for TR.
Better long-term results are observed with
prosthetic rings than with the suture
annuloplasty,
 The incidence of residual TR being,
respectively, 10% vs 20–35% at 5 years.
Indications for Tricuspid Valve Surgery
Severe Right Ventricular
Dysfunction????
ESC 2012 VHDGuidelines
Indications for Tricuspid Valve
Surgery
If secondary TR is less than severe, the diameter of the
tricuspid annulus rather than the grade of regurgitation
(which is highly subjective and variable) should be the
criterion to indicate the need for concomitant TV repair at the
time of mitral valve (MV) surgery
Assessment of RV Function
The echocardiographic quantitative assessment
of right ventricular (RV) function has been
difficult owing to the complex RV
anatomy.
Identifying an accurate and reliable
echocardiographic parameter for the
functional assessment of the RV still remains
a challenge
Assessment of RV Function
 It has a complex geometry, appearing
triangular when viewed from the front, and
crescentic when viewed in a transverse
section of the heart
 Cannot be fitted to simple geometric models
Limitation of 2D
Essential Imaging Windows and Views-1
Essential Imaging Windows and Views-2
Essential Imaging Windows and Views-3
Essential Imaging Windows and Views-4
Essential Imaging Windows and
Views-5
Essential Imaging Windows and Views-6
Right Heart Dimensions
ASE 2010
Right Ventricle Dimensions
The sensitivity
of right
ventricular
sizewith angular
change
Ensure that the
RVis not
foreshortened
and that the
LVoutflow tract is
not opened up
(avoid the apical
5-chamber view)
RV Dimensions
RV basal dimension <42 mm
(RVD1)
RVOT Dimensions
RVOT proximal diameter <33 mm
RVOT proximal diameter <27mm
RV Systolic Function-FAC
RV FAC = EDA-ESA/EDAX100
RV FAC <35%
Prognostic value +
Correlation with
MRI derived EF
RV Systolic Function-2D RVEF
2D RV EF is not recommended, because of the
heterogeneity of methods and the numerous
geometric assumptions
ASE 2010
RV Systolic Function-3D RVEF
 Three-Dimensional Volume Estimation
 RV end-diastolic volume <89 mL/m²
 RV end-systolic volume <45 mL/m²
(10% to 15% lower in women)
The lower reference limit for RV EF is 44%
Excellent correlation with MRI derived EF
RV Systolic Function-3D RVEF
RV MPI
MPI = IVRT+IVCT/ET
TissueDoppler derived
MPI
>0.55 RV
dysfunction
TAPSE
TAPSE may not
reflect whole RV
systolic function
<16 mm RV dysf.
Correlation with
isotropic derived
RVEF
Prognostic value in
HF
Doppler Tissue Imaging
Cut-off value of 11.5 cm/s for tricuspid ring systolic
velocities is able to accurately predict global RV
dysfunction (defined as RVEF <45%).
Myocardial Acceleration During
Isovolumic Contraction
IVA measured in the basal segment of the RV free wall
of > 1.1 m/s2 correlates well with MRI RVEF >45%
(90% sensitivity and specificity).
Angle dependent
Load independent
RV Strain and Strain Rate (STE)
Strain Percentage change in myocardial
deformation
Strain rate rate of deformation of myocardium
over time
 Reflect regional and global RV functions
 Less load dependent
RV Strain and Strain Rate (STE)
LV eccentricity index (EccIx)
 EccIx, defined as the ratio of the LV antero-posterior to septo-
lateral diameters in a short-axis view
 EccIx >1 at end-diastole  volume overload
 Ecclx>1 at end systole and diastole pressure overload
ASE-Right Heart Evaulation
 Examine the right heart using multiple acoustic
windows
 Report should represent qualitative and
quantitative parameters.
RV size
RA size
RV systolic function (at least one of the
following):
Fractional area change [FAC]
TAPSE
S`
SPAP
ESC 2012-VHD Guidelines
 Evaluations of the RV dimensions and
function should be conducted, despite
existing limitations of current indices of RV
function.
TAPSE <15 mm
St <11 cm/s
RVED area > 0.20 cm²
could be used to identify patients with RV
dysfunction