Tricuspid Valve:Imaging and Quantification.

The Role of the Right Ventricle

Theodora A Zaglavara, MD, PhD

Cardiologist – Cardiac Imaging Department

INTERBALKAN MEDICAL CENTER THESSALONIKI

No Disclosures

Anatomy of the Tricuspid Valve

Goals of Imaging• TR severity

• TR severity

• TR mechanism

• Mode of leaflet coaptation

• Degree of tricuspid annulus enlargement and tenting

• RA dimensions

• RV morphology and function

• PASP

• Planning for Interventions

Imaging Modalities

• 2-D TTE /TEE Echo

• 3-D TTE/TOE Echo

• Cardiac CT

• Cardiac MRI

Mechanism of TR -2D Echo EbsteinAnomaly

Myxomatous TraumaticIatrogenic

Mechanism of TR -2D Echo

Post MVRRV dysfunction

ASD – LR shunt

Which Leaflet in Which View? The Added Value of 3-D Imaging

3-D TTE Location of Lead Device Position and Mechanism of TR

Mediratta et al, JACC Imaging 2014

3-D Echo: New Insights into Functional Tricuspid Regurgitation

Mechanisms • Pulmonary Hypertension• Papillary muscle

displacement• Annular dysfunction or

dilatation

The Complex- Dynamic Nature of the Tricuspid Annulus

The Complex- Dynamic Nature of the Tricuspid Annulus

Tricuspid Annulus Shape and Dimensions by Cardiac CT

Assessment of Tricuspid Regurgitation Severity

✓ Grading TR severity is in principle similar to MR

✓ However TR is more load dependent than MR

✓ The color flow area of the regurgitant jet is not

recommended to quantify the severity of TR

✓ The color flow imaging should only be used for diagnosing

TR

✓ A more quantitative approach is required when more than a

small central TR jet is required

Echocardiographic Evaluation of TR Severity

Vena Contracta

The systolic hepatic flow reversal is specific for severe TR. It represents the strongest additional parameter for evaluating TR severity.

Quantitative Echo Assessment of TR Severity : EROA and Regurgitant Volume

PISA radius: 0.82 cm EROA =0.53 cm²TR VTI= 91.4 cm TR RV:49 ml

3-D Vena Contracta Area : Good correlation with EROA

CMR in TR and Right Heart Visualization & Quantitation

Severe TR is defined as TR jet area > 10 cm2, ratio of jet-right atrium (RA) area > 35%, regurgitant orifice area > 40 mm2, and VC > 7 mm (arrows).

The Complex Relationship between TR and RV function

Tricuspid Valve Annulus Size and Degree of Tenting is Related to RV Remodeling

Tending Distance > 0.8 cmTending Area>1 cm² -Severe TR

Chronic Severe TR always leads to dilated RV and RA

Conventional echo variables of RV function and even 3D or CMR derived RV ejection fraction are well known to be load dependent and not to be a proper reflection of RV contractility.The real impact of severe TR on intrinsic RV contractile function and on its potential reversibility is therefore difficult to assess.Preserved RV function variables in the presence of significant TR are always associated with a better prognosis than altered ones.

RV Function: Keep it Simple!

3D RVEF < 45% is considered abnormalTAPSE <15 mm indicates significantly reduced RV systolic functionTDI systolic S’ velocity < 11cm/s correlates with RVEF <45%RV 2-D strain <-20 is considered abnormal

Thank you for your Attention!!!