echocardiographic evaluation of tricuspid...
TRANSCRIPT
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Muhamed Sarić MD, PhD, MPADirector of Noninvasive Cardiology | Echo LabAssociate Professor of Medicine
Echocardiographic Evaluation of Tricuspid Valve
2017 SOTA, Tucson, AZ
February 18, 2017 | 9:00 – 9:25 AM | 25 min
Disclosures
Speakers Bureau (Philips, Medtronic)Advisory Board (Siemens)
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Anatomy of Tricuspid Valve
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Anatomic Specimen Drawing of Tricuspid Valve
Leonardo did notuse the term
‘tricuspid valve’ as it has not been invented yet.
Drawn circa 1512-13British Royal Collection
Leonardo probably drew an ox heart.
He referred to valves as
‘heart sieves’.
Probably the first drawing of a dissected tricuspid valve was done by Leonardo da Vinci.
Leonardo da Vinci(1452 – 1519)
Self-portrait c. 1512
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Who Named Mitral & Tricuspid Valves
MITRAL VALVE
--------------------Andreas Vesalius
1543
Andreas Vesalius
Flemish Anatomist(1514 – 1564)
TRICUSPID VALVE
----------------------GaspardBauhin
1597
Gaspard Bauhin(Bauhinus)Swiss Physician
(1560 - 1624)
Terms ‘mitral’ and ‘tricuspid’ valves have been in continuous use for more than 500 years!
Tricuspid Valve Anatomy
3 LEAFLETS
(anterior, septal & posterior)
CHORDAE TENDINEAE
3 PAPILLARY MUSCLES
RIGHT VENTRICULAR MYOCARDIUM
TRICUSPID ANNULUS
Image source: University of Toronto
SA
P
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Variability in Tricuspid Valve AnatomyNUMBER OF LEAFLETS
Between 2 and 6NUMBER OF PAPILLARY MUSCLES
Between 2 and 9
Surg Radiol Anat 1990;12:37-41
Only in a minority of humans the tricuspid valve is truly
trileaflet.
Tricupid valve is most commonly a 4-leaflet valve.
Tricuspid Valve: Autopsy Specimen
Van Mierop Archive, University of Florida
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Tricuspid Valve VideographyIntracardiac video recordings performed after the blood is replaced with a transparent, oxygen-carrying fluid.
Anterior
Septal
Posterior
3D TEE: Tricuspid Valve
Anterior
Posterior
Septal
Right Atrial Side Right Ventricular Side
Anterior
Septal
Posterior
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Tricuspid Valve Guidelines
Echo Assessment of Tricuspid ValveTricuspid valve should be evaluated based on national and international guidelines.
2003 – ASE Native Valve Regurgitation
2008 – ASE Native Valve Stenosis
2009 – ASE Prosthetic Valves
Number of Pages Devoted To
MV + AV TV + PV Ratio
This reflects the fact that echocardiographic methods for evaluation of right-sided valves are less validated than those for the left-sided valves.
2014 – ACC/AHA Valve Disease
11
15
10½
5½
4
5½
2:1
4:1
2:1
36 6 6:1
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Prevalence of Tricuspid Regurgitation
-
500,000
1,000,000
1,500,000
2,000,000
2,500,000
3,000,000
Severe AS Mod-SevereTR
Mod-Severeor Severe MR
Nu
mb
er o
f P
atie
nts
Valvular Disease Opportunity in US(2006 Estimate)
Total # of Patients
Currently TreatedSurgically
J Thorac Cardiovasc Surg 2006;132:1258-61
Echocardiographic View of Tricuspid Valve
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Echocardiographic Evaluation of Tricuspid Valve
Tricuspid Valve Anatomy
Primary ways of quantification
Ancillary Methods
Tricuspid Valve: 2D TTE Views
Short-Axis View at Aortic Valve Level
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Tricuspid Valve: Short-Axis View
1 2
1---------------------Posterior leaflet
in most cases
2----------------------------------
50/50 chance of either septal or anterior leaflet Int J Cardiovasc Imaging 2007;23:717–724
Tricuspid Valve: TTE Views
Right Ventricular Inflow View
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Tricuspid Valve: RV Inflow View
1
2
1----------------------------
Either posterior or septal leaflet
2-----------------------------
Anterior leaflet in most cases
Int J Cardiovasc Imaging 2007;23:717–724
Tricuspid Valve: TTE Views
Apical 4-Chamber View
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Tricuspid Valve: A4C View
1 2
1-------------------Anterior leaflet
2----------------Septal leaflet Int J Cardiovasc Imaging 2007;23:717–724
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Tricuspid Valve: 2D TEE
Transgastric Tricuspid Valve
Short-Axis View
Tricuspid Valve: 2D TEE
Transgastric Tricuspid Valve
Short-Axis View
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Tricuspid Regurgitation
Tricuspid Regurgitation | Etiology
SECONDARY
(FUNCTIONAL)(80%)
PRIMARY
(20%)
• Ebstein’s• Carcinoid• Rheumatic• Traumatic• PPM/ICD lead
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Primary Tricuspid Regurgitation | EndocarditisStaphylococcus aureus vegetation in an IVDA
Primary Tricuspid Regurgitation | Trauma17-year-old male with a gun-shot wound
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Primary Tricuspid Regurgitation | Carcinoid Disease
Carcinoid Disease | 3D TTE – LV Perspective
Frozen Tricuspid Valve
Normal Mitral Valve
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Primary TR: Rheumatic Heart DiseaseWoman with mechanical MV & AV for rheumatic heart disease; residual native TV disease
Primary TR: Ebstein’s Anomaly
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Primary TR: Ebstein’s Anomaly
Secondary Tricuspid Regurgitation
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Quantification of Tricuspid Regurgitation
Primary ways of
quantification
Color Doppler is the primary means for quantifying tricuspid regurgitation.
Method SEVERE TR--------------------------------Size at Nyquist limit 50-60 cm/s
Jet Area > 10 cm2
PISA Radius > 0.9 cm
Vena Contracta > 0.7 cm
Evaluate TR in Multiple Views
Apical 4-Chamber View
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Evaluate TR in Multiple Views
RV InflowView
Evaluate TR in Multiple Views
Hepatic VeinView
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Primary Means of Quantifying TR
MILD TRJet area < 5 cm2
MODERATE TRJet area 5 - 10 cm2
SEVERE TRJet area > 10 cm2
Semiquantitative assessment of TR severity using regurgitant jet size in the right atrium.
ASE GUIDELINES
Absolute TR Jet Area
FRAMINGHAM
Relative TR Jet Area(Jet Area / RA Area)
JA/RA Area < 20% JA/RA Area 20 - 40% JA/RA Area > 40%
All these values apply primarily to central (non-Coanda) jets.
TV Regurgitation: PISA & Vena Contracta
PISA RADIUS
0.7 cmVENA CONTRACTA
0.5 cm
CONCLUSION
Tricuspid regurgitation is less than severe.----------------------------------------------------------------TR is severe when PISA r > 0.9 cm and VC > 0.7 cm
Nyquist 50 t0 60 cm/s
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Ancillary Methods for Assessing Tricuspid Regurgitation
.1.Right Heart Size
Big RA & RV & IVC in chronic TR
Normal RA & RV size in acute TR
Native tricuspid valveEmax > 1.0 m/s
suggests severe TR
.2.E Wave Velocity
.3.Hepatic Veins
S wave reversalis sign of
severe TR.
S S
DD
2/17/2017NYU LEON H. CHARNEY DIVISION OF CARDIOLOGY
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Shapes of Spectral TR Jet
Seen e.g. in severe TR when RA pressure is very high
(as in acute TR).
Seen e.g. in less than severe TR or in severe TR when RA pressure is not
very high.
Early peaking, rapidly decelerating TR jet.Such jets are often laminar on color Doppler.
TRIANGULAR SHAPE
Broad-based, symmetric TR jet.Such jets are turbulent on color Doppler.
PARABOLIC SHAPE
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Shapes of Spectral TR Jet
Seen e.g. in severe TR with normal RV systolic pressure
Forward and reverse flow signals across TV are almost mirror images of each other.
TO-AND-FRO FLOW
Note the laminar nature of TR jet.
Tricuspid Stenosis
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2/17/2017NYU DIVISION OF CARDIOLOGY
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Normal Valve Areas
Normal MITRAL valve area in adult humans is
roughly the size of a US quarter.
-------------------------4-6 cm²
Normal TRICUSPID valve in adult humans is roughly
the size of a US half-dollar coin.
----------------------------6-8 cm²
Normal AORTIC valve in adult humans is roughly
the size of a US nickel or dime.
----------------------------2-4 cm²
Echocardiographic Evaluation of Tricuspid Valve
Tricuspid Valve Anatomy
Primary ways of quantification
Ancillary Methods
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Quantification of Tricuspid Stenosis
Primary ways of
quantification
Continuous Wave Doppler is the primary means for quantifying tricuspid stenosis.------------------------------------------------------------------------------------------------------
Because of normally significant respiratory variations in tricuspid inflow, either average several beats or use end-expiratory apnea beats.
Method HEMODYNAMICALLY SIGNIFICANT
TRICUSPID STENOSIS
Mean gradient (at HR 70-80 bpm) > 5 mm Hg
Inflow VTI > 60 cm
Pressure Half-time > 190 msec
Valve area (by continuity equation) < 1 cm²
J. Am. Coll. Cardiol. 2010;55;1996.
3D TTETricuspid Valve Planimetry
TVA < 1 cm2
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Ancillary Methods for Assessing Tricuspid Stenosis
.1.Right Atrial Size
Moderate or severe RA enlargement
supports the diagnosis of
significant tricuspid stenosis.
Dilated inferior vena cava and other sings of elevated RA
pressure
.2.Right Atrial Pressure
CARCINOID DISEASE
Tricuspid Stenosis | Anatomy
Right Atrial Lymphoma
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Tricuspid Stenosis | Anatomy
Right Atrial Lymphoma
Tricuspid Stenosis | Hemodynamics1. High antegrade velocity across TV2. High diastolic VTI and mean gradient3. Respiratory variations in tricuspid inflow4. Difficulty of measuring P½ at high heart rate
Mean ΔP = 7-12 mm Hg
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Tricuspid Stenosis | Ancillary Signs
Dilated & noncollapsing IVC (high RA pressure)
New York University Langone Medical Center
Thank You!