Lang - 300pm -Assessment of Tricuspid and Pulmonic Valve ... · 3/14/2018 1 Roberto M Lang, MD...

3/14/2018

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Roberto M Lang, MD

Assessment of Tricuspid and Pulmonic Valve Disease:

Importance of 3D

M-mode

2D Echocardiography

Anterior

Septal

Anterior

Septal

SeptalPosterior

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THE TV ON 3D ECHO

S

A PA

S

P

RV perspective RA perspective

THE TRICUSPID VALVE: ADDED VALUE OF 3D IMAGING

x

y

x

y

z

2D 3D

< 5% of pts ~ 85% of pts

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THE NORMAL TRICUSPID VALVE COMPLEX

1. Three leaflets Anterior Septal Posterior

2. Fibrous annulus3. Chordae tendinae4. Papillary muscles5. RA myocardium6. RV myocardium

Courtesy Dr. Stephen P. Sanders, Professor of Pediatrics (Cardiology),

Harvard Medical School

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HOW MANY LEAFLETS DOES THE TRICUSPID VALVE HAVE?

• 36 adult human hearts • # leaflets vary from 3-7• Extra leaflets are called

“accessory leaflets”• Accessory leaflets are

common

Typical three-leaflets

Seven leaflets (4 accessory leaflets)

16.6%

16.6%

Lama P, et. al. Anat Sci Int. 2016 Mar;91(2):143-50.

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AMBIGUITY OF LEAFLET IMAGED ON 2D

SA

P

S A

P

RV inflow view

AMBIGUITY OF LEAFLET IMAGED ON 2D

SA

P

SA

P

Apical4-chamber

view

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Basal SAX view

Anteriorleaflet

Aorta and single leaflet

Posteriorleaflet

P

A

S

Anteriorleaflet

Aorta and two leaflets

Aorta

Aorta

Anterior or septal leaflet

Posterior or anterior leaflet

P

A

S

Posteriorleaflet

Septalleaflet

LVOT/septum and two leaflets

LVOT

PS

A

J Am Soc Echocardiogr 2016;29:74-82.)

Anteriorleaflet

Septal or posterior leaflet

S

P

A

RVIF view

Septalleaflet

Septalleaflet

P

AS

PA

S

Posteriorleaflet

2D view without septum 2D view with septum

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Post LVAD study

13Presentation Title Here |

RV inflow view

S

PA

RV inflow view 2

S

PA

S

A

P

A


RV inflow view #1 RV inflow view #2

S

A

Mild TR Severe TR

S

A

P

A

Post LVAD study

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Septal leaflet

Anterior or posterior leaflet

Anteriorleaflet

SP

A

5-chamber view

LVOT

Apical view

Coronarysinus

A

P S

Posterior leaflet

4 CV

J Am Soc Echocardiogr 2016;29:74-82.)

MECHANISMS OF TRICUSPID REGURGITATION

Primary(or “Organic”)

Secondary (or “Functional”)

Intrinsic abnormalityof the valve apparatus

TV annular dilatation, RV dilatation and papillary muscle displacement

70-85%* of TR15-30%* of TR

Antunes MJ, Barlow JB, Heart 2007

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Primary/Organic TR –PPM/ICD Device Location

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RV inflow

A4C

ICD inserted and echo performed 8 days later

26 year-old with dilated cardiomyopathy on the transplant list

RV perspective

RA perspective

Severe TRA4C

RV inflow

Pre-ICD

Post-ICD

P-S COMMISSURE:

CORRECT POSITION

A:

Postero-septal Antero-posterior Middle Antero-septal

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• Primary (Organic) TR – Pacemaker/ICD89 year-old man with right heart failurePast medical history: CAD, MV repair, TAVI in 2009• Permanent pacemaker implantation post TAVI for bradycardia

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PACEMAKER ADHERENCE

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FUNCTIONAL TRICUSPID REGURGITATION

Chronic PE, Lung disease

RV ischemia, VOL, CM

Left-sided valve disease

Atrial fibrillation

L-R shunt

FTR

Dreyfus G. J Am Coll Cardiol 2015;65:2331–6

TA dilatationRV enlargementPM displacement

TV tethering

70-85%* of TR

TRICUSPID VALVE ≠ MITRAL VALVE

Different valve orifices Different subvalvular apparatuses Different ventricles

Yet TR and MR are assessed in similar ways

Tricuspid valve Mitral valve

≠

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JASE 2017

GRADING OF TRICUSPID REGURGITATION SEVERITY

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TR IS LOAD DEPENDENT

64 year-old man with a NICM

LVEF – 20%

Functional TR


Tricuspid annulus dilatation may be a more reliable indicator of TV pathology than degree of regurgitation

Good correlation between TA diameter and TR regurgitant volume

46 mm

TR varies depending on preload, afterload, RV function

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Pre and post peritoneal dialysis

Normal tricuspid annular dimension


TA = 51 mm TA = 55 mm

TopilskyY et. al. Circulation 2010;122

TR depends on respiratory

phase

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Functional TR and annular dilatation


The annulus is dilated if it measures1. > 40 mm or > 21 mm/m2 on 2D

transthoracic echocardiography–Apical 4-chamber view–In diastole

2. > 70 mm on direct intraoperative measurement

ACC/AHA Guidelines for management of VHD JACC 2014

ESC/EACTS Guidelines for management of VHD EHJ 2012

IMPORTANCE OF THE TRICUSPID ANNULUS

Dreyfus et al. Ann Thorac Surg, 2005

Despite a sicker MV +TV repair group…

Survival @ 10 years 90.3% 85.5% p=NS

Grade III-IV TR 1% 34% p<0.001

Class III-IV CHF 0% 14% P < 0.01

MV + TV repair MV repair only

Performing tricuspid annuloplasty based on TA dilatation rather than TR degree results in improved surgical outcome

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•TA size measured by 2D echocardiography should be interpreted with caution because it is underestimated by both 2D TTE and TEE.

ROLE FOR 3D ECHOCARDIOGRAPHY

• Better approximation of septal-lateral dimension • Also allows measurement of antero-posterior dimension

Addetia K, Muraru D, Veronisi F, Badano LP, Lang RM et. al. work in progress

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Software-generated annulus

Long-axis dimension

RV focused view dimension

Traditional 4-chamber dimension

Short-axisdimension

Addetia K, Muraru D, Veronisi F, Lang RM, Badano LP et. J Am Coll Cardiol (in press)

On the horizon…

3D Echo

TRICUSPID ANNULUS

Saddle-shaped• High points antero-posterior

• Low points medial-lateral

Ellipsoid shape

Courtesy F. Veronesi, PhD.

Ton-Nu Circulation. 2006

RA

Apex

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FUNCTIONAL TRICUSPID REGURGITATION

TA dilatation occurs mostly along the RV free-wall Septal portion of the tricuspid annulus relatively fixed

Dreyfus et al. ATS 2005

FUNCTIONAL TRICUSPID REGURGITATIONNormal Functional TR

Non‐planarity angle = 158° Non‐planarity angle = 173°

With worsening TR, the annulus becomes larger, rounder and flatter

Taramasso M et al. J Am Coll Cardiol 2012

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TR s highly dependent on annular dilatation, with significant TR occurring with only 40% dilatation, whereas it was seen at 75% dilatation in vitro MV studies. i.e. the TV leaks earlier that the MV Spinner EM. Circulation 2011

THE ACC/AHA 2014 GUIDELINES

ACC/AHA Guidelines for management of VHD JACC 2014

ESC/EACTS Guidelines for management of VHD EHJ 2012

TA dilated if >40 mm in apical 4-chamber view

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Pre-operative TR, TV tethering distance and TV tethering area were independent predictors of residual TR after annuloplasty. Tethering distance 0.76 cm and tethering area 1.63 cm2 had the best AUC (0.88 and 0.87 respectively)

Fukuda Circulation 2005

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RV basal dimensionRV length

Group (N) Controls (99) Id FTR (141) PHTN FTR (140)TR None Matched for ERO

sPAP Normal <50 mmHg ≥ 50 mm HgAssociations: Controls Aging, Afib

TA Normal

Tenting Normal Normal

RV Base Normal

RV Length Normal Normal

Remodeling -- Conical EllipticalTopilskyY, Circ Cardiovasc Imaging. 2012;5:314-323


Tenting volume >2.3 cm3

Min SY et al. Eur Heart J 2010

TV tenting volume by 3DE (accounting for both enlarged annulus area and leaflet tenting) is the major determinant

of residual functional TR after annuloplasty

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NEW DIRECTIONS: EVALUATION OF FTR A MORE COMPREHENSIVE APPROACH

Dreyfus et. al. JACC 2015

ON THE HORIZON…

Muraru D…et. al. European Heart Journal Cardiovascular Imaging

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BEWARE… THE ULTRASOUND BEAM OFTEN ELICITS FINDINGS THE HISTORY

AND PHYSICAL EXAM CANNOT…

Thank you!

Lang - 300pm -Assessment of Tricuspid and Pulmonic Valve ... · 3/14/2018 1 Roberto M Lang, MD...

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Transcript of Lang - 300pm -Assessment of Tricuspid and Pulmonic Valve ... · 3/14/2018 1 Roberto M Lang, MD...