TR is a common echocardiographic finding. Nath and colleagues evaluated 5223

patients who had undergone echocardiography at laboratory within a 4-year

period.

The TR incidence was 88.5%, with 15.5% having moderate or greater TR

Type TR - Primary

- Secondary/Functional (MC) (80-85%)

Etiology of FTR

Left heart disease

Chronic Pulmonary Disease

Primary pulmonary Hypertension.

FTR has poor prognosis if it is not treated- leads to irreversible right ventricular

dysfunction and failure.

There is a strong impact of TR on clinical outcome.

Significant TR is associated with poor prognosis in patients with mitral stenosis

after percutaneous balloon valvuloplasty and with a reduction in exercise capacity

after mitral valve surgery.

A significant increase in mortality among patients with moderate and severe TR has

been reported, which was independent of left ventricular ejection fraction or

pulmonary artery pressure.

In 60 patients with flail tricuspid leaflet due to trauma, significant increases in

atrial fibrillation, heart failure, and death were observed.

TR was also an independent predictor of increased mortality in 1400 patients with

left ventricular systolic dysfunction.

According to a review of 5223 patients, the 1 year survival rate was about 90%-

no/mild TR, 79% for moderate TR, 64% for severe TR, independent of age.

Sagie A. JACC,1994;24:696–702; Nath J. J Am Coll Cardiol 2004;43:405–409

Matsuyama and colleagues followed up 174 patients without FTR repair for a mean

of 8.2 years. During follow-up, 16% had developed FTR of grade 3 or more.

Dreyfus and colleagues corrected the FTR in 311 patients according to the anatomic

criteria (intraoperative diameter > 70 mm). After a mean follow-up of 4.8 years, the

FTR grade had changed from 0.88 to 0.36 in the treated patients and from 0.82 to

2.07 in the untreated patients (P<.001), with 48% of the patients having an increase

to FTR grade 2 or more.Michal Smid et. al Cardiology Research and Practice, 2010, 5.Dreyfus et al .Ann Thorac Surg.2005;79:127-32.

Matsuyama et al. Ann Thorac Surg. 2003;75:1826-8.

One small study on only 39 patients showed that in addition to tricuspid

valve tethering, left ventricular as well as right ventricular function and

pressure influence repair durability.

Recent data from the Cleveland clinic on 2000 patients report a high

recurrence rate of significant TR years after surgery, irrespective of the

mode of repair.

By 3 months after surgery, 34% of patients had moderate or severe TR,

which increased to 45% of patients at 5 years.

Fakuda et al. Circulation 2006:114:I-582–I-587.

Navia Jl et al. J Thorac Cardiovasc Surg 2010;139:1473–1482.

Detect TR

Estimate severity

Assess pulmonary HTN

RV function

LV function

Tricuspid annulus

Color doppler- visual assessment of color jet area is a quick intial screening

Measurement of Vena contracta-

Regurgitation jet area

EROA and regurgitation volume measurement - PISA method – laborious.

PISA and vena contracta corelate well in TR, VC prefered.

Doppler examination-CW- used for estimation of RVSP- Maximum TR jet

velocity measured and pressure calculated by Bernoulli equation(p=4V2).

PW confirmed severe TR- as jet velocity > 1m/s

Vena contract width > 6.5mm

Annulus dilatation > 40mm or inadequate cusp coaptation

Regurgitation volume > 45 mL

Increased tricuspid inflow velocity > 1m/s

ERO > 0.4cm2

Color flow regurgitant jet area > 30% of RA area.

Systolic flow reversal in the hepatic vein.

The ECHO Manual

Tricuspid valve repair in conjunction with mitral valve surgery

is beneficial for severe TR and should be considered for less

than severe TR when there is dilated annulus (>40mm) or

pulmonary hypertension.

Tricuspid valve repair consider when annulus diameter is

twice the normal.

Many patients with normal annular diameter has TR grade 1or 2.

Many patients can have significant FTR even if the TA

dimensions are within the normal range.

Normal TA – 25-28mm

TA diameter cant be the only determinant indication for surgery.

Right ventricular longitudinal/systolic

function.

Measure at tricuspid lateral annulus.

Normal Range- 1.5-2.0 cm,

Value < 1.6 consider as abnormal.

Event free survival rate according to

TAPSE in CHF

TV is complex structure

With 2D Echo it is difficult to see all three leaflet

Anwar et al found that both the septal and anterior leaflets were

visualized in 100% of patients in the parasternal short-axis and apical

four-chamber views. The posterior leaflet was seen only in the

parasternal short-axis view (92% of patients), and the second leaflet

seen in this view was variable (septal in 48%, anterior in 52%).

Difficult to assess coaptation of 3 leaflets

Anwar et al. Int J Cardiovasc Imaging. 2007;23:717–24.

Real-time 3D echocardiography allows for rapid acquisition and

viewing of high-quality images.

3DE can visualize the valve from the right atrial or “surgeon’s”

view, so that all three leaflets may be viewed.

The ability to visualize all three tricuspid leaflets simultaneously is

a major advantage of 3DE.

Badola LP et al. Eur J Echocardiogr. 2009;10:477–84.

CMLVEDV: 115 ml;LVESV: 38 mlFE: 66%Gmed Mitrale: 6 mmHgAortic Velocity: 2Tricuspid GM: 1 mmHgTricuspid annulus D: 22 mm TR: MILDTAPSE: 1.5 cmVolume RV: 6.7 Dya, 6.4 Sys

DGLVEDV: 115 ml;LVESV: 64 mlFE: 55%Gmed Mitrale: 1,2 mmHgAortic Velocity: 0.9Tricuspid Gmed: 0.7 mmHgTricuspid annulus D: 19mm TR: MILDTAPSE: 2.8cmVolume VD: 27 Dya, 14,5 Sys

BM:LVEDV: 99 ml;LVESV: 43 mlFE: 60%GM Mitrale: 3.8 mmHgAortic Velocity: 1.1Tricuspid GM: 0.8 mmHgTricuspid annulus D: 24 mm TR: MILDTAPSE: 2.4cm Volume VD: 16 Dya, 7 Sys

MG:

TR- MILD

PAP-normal

HN:

TR- severe

Admitted in ITU.

SM:

Not traced

TR is common echocardiographic finding in general population

Prognosis of severe TR is not good, among LHF patients it is

independent predictor of event free and overall survival.

Diagnosis and thorough assessment of TR is key to success

Annular diameter can`t be only parameter to be consider for surgical

intervention.

Durability of T annuloplasty need to checked

Prophylactic TR intervention during other cardiac surgery is

debatable.

Randomized controlled trials need to answer these issues