Echocardiographic Evaluation of Tricuspid...

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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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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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RV InflowView


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



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!

Echocardiographic Evaluation of Tricuspid...

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