Isolated prolapse of the tricuspid valve

Severe tricuspid regurgitation with biannular disjunction requiring surgical treatment: a case report

Background

Tricuspid annular disjunction (TAD) is an annular disjunction of the right-sided heart. Although TAD is often concomitant with mitral annular disjunction (MAD), it often presents as mitral regurgitation (MR), rather than tricuspid regurgitation (TR). While the clinical significance of MAD has been well-established, there is still little data on TAD. This is a rare case of severe TR due to TAD that appears to be isolated from MAD.

Case summary

A 63-year-old female complaining of pre-syncope and dyspnoea on exertion was referred to our department. Initial transthoracic echocardiography showed MR and TR due to tricuspid valve prolapse (TVP). On transoesophageal echocardiography, the TVP consisted of an excessively redundant anterior leaflet, where the annular disjunction and severe regurgitation were formed. She recently underwent mitral and tricuspid valve plasties for symptomatic primary severe TR.

Discussion

This case report emphasizes the clinical significance of TAD as a potential cause of severe TR, even without significant MR. Tricuspid annular disjunction progresses more gradually compared with MAD. This case suggests that remodelling of the right atrium, particularly in chronic atrial fibrillation, may contribute to the development of TR. Despite diagnostic challenges due to the flexible and dynamic nature of the tricuspid annulus, this is the first report of TAD-induced severe TR necessitating surgical intervention. Accurately diagnosing TAD remains challenging with current imaging modalities, emphasizing the need for improved diagnostic tools to optimize treatment strategies.

Tricuspid Annulus Disjunction: Novel Findings by Cardiac Magnetic Resonance in Patients With Mitral Annulus Disjunction

OBJECTIVES

This study aimed to assess whether patients with MAD also have disjunction of the tricuspid annulus.

BACKGROUND

Mitral annulus disjunction (MAD) is an abnormal atrial displacement of the mitral annulus. Whether the disjunction extends to the right side of the heart is not known.

METHODS

In a cohort of patients with MAD, we assessed the presence of tricuspid annulus disjunction (TAD) with the use of cardiac magnetic resonance. We explored the associations between TAD and MAD characteristics and the relationship to ventricular arrhythmias (nonsustained/sustained ventricular tachycardias and aborted cardiac arrest).

RESULTS

We included 84 patients (mean age: 48 ± 16 years; 63% female). We observed TAD in 42 (50%). Patients with TAD were older (age 52 ± 16 years vs. 43 ± 15 years; p = 0.02), had greater circumferential extent of MAD (164 ± 57° vs. 115 ± 58°; p = 0.002), greater maximum longitudinal MAD distance (9.4 ± 2.9 mm vs. 6.2 ± 2.8 mm; p < 0.001), and more frequent mitral valve prolapse (n = 39 [92%] vs. n = 24 [57%]; p < 0.001). Ventricular arrhythmias had occurred in 34 patients (41%), who were younger (age 39 ± 14 years vs. 54 ± 14 years; p < 0.001) and had lower prevalence of TAD (n = 22 [29%] vs. n = 12 [52%]; p = 0.03). TAD was not associated with ventricular arrhythmias when adjusted for age (odds ratio adjusted for age: 0.54; 95% confidence interval: 0.20 to 1.45; p = 0.22).

CONCLUSIONS

We report for the first time the existence of right-sided annulus disjunction as a common finding in patients with MAD. TAD was associated with more severe left-sided annulus disjunction and mitral valve prolapse, but not with ventricular arrhythmias.

Characteristics and Significance of Tricuspid Valve Prolapse in a Large Multidecade Echocardiographic Study

BACKGROUND

Characteristics of tricuspid valve prolapse (TVP) on transthoracic echocardiography are not well defined. As tricuspid valve interventions are increasingly considered, information on the definition and clinical significance of TVP is needed.

METHODS

At the authors' institution, between January 26, 2000, and September 20, 2018, 410 patients (0.3%) were determined to have suspected TVP. These transthoracic echocardiograms and those of 97 age- and sex-matched normal control subjects were reviewed. Interrater agreement on TVP by visual inspection was assessed in a blinded subset. Leaflet atrial displacement (AD) > 2 SDs above the mean in normal control subjects was used to identify an empiric definition of TVP Features of patients meeting this definition were evaluated.

RESULTS

Three hundred twelve transthoracic echocardiograms with available and interpretable images (76.1%) were included. Interrater agreement on TVP diagnosis by visual inspection was moderate. Normal values of AD were up to 4 mm in the right ventricular inflow view and 2 mm in all other views. AD > 2 mm in the parasternal short-axis view had the best accuracy against suspected TVP to identify TVP. Those with TVP by this definition more frequently had 3 to 4+ tricuspid regurgitation (22.2% vs 3.1%; P < .001), mitral valve prolapse (MVP; 75.0% vs 3.1%; P < .001), and more clinically significant MVP (greater prevalence of 3 to 4+ mitral regurgitation). No difference in mortality was observed in those with isolated TVP versus TVP and MVP (log-rank P = .93).

CONCLUSIONS

In the largest study of TVP to date, interrater agreement on TVP diagnosis by visual inspection was moderate. A cutoff of >2-mm AD in the parasternal short-axis view was optimal to define TVP. Those with TVP by this definition had more significant tricuspid regurgitation, larger right ventricles, and more clinically significant MVP. Overall, these results suggest an increased role for surveillance for TVP and the need for clear diagnostic criteria in updated guidelines.

The Degree of Left Ventricular Hypoplasia Is Associated with Tricuspid Regurgitation Severity in Infants with Hypoplastic Left Heart Syndrome

Tricuspid valve regurgitation (TR) increases adverse outcomes in children with hypoplastic left heart syndrome (HLHS). Changes in tricuspid valve (TV) annulus and leaflet geometry have been described but the underlying causes for TR in HLHS remain uncertain. We aimed to examine the association between left ventricular (LV) size and TR in infants with HLHS as right ventricular (RV)-LV interactions may be important in TR development. Echocardiograms of 50 infants with HLHS were reviewed. LV size, RV function, TR grade, TV annulus z-score, and aortic arch obstruction were examined at birth and 1 year of age (or the latest study post-bidirectional Glenn anastomosis if the patient was < 1 year of age). 24/50 (48%) had severe LV hypoplasia and 26/50 (52%) had mild/moderate LV hypoplasia. At 1 year, 10/24 (42%) with severe LV hypoplasia had moderate/severe TR versus 0/26 in the mild/moderate LV hypoplasia group (p = 0.0002). TR progressed ( ≥ 1 grade) in 14/24(58%) with severe LV hypoplasia versus 5/26 (19%) with mild/moderate LV hypoplasia (p = 0.008). In this cohort, no association was found between the degree of TR and either RV function, TV annular z-score, or arch obstruction; or between the degree of LV hypoplasia and either RV function or TV annular z-score. In infants with HLHS, the severity and progression of TR is associated with the severity of LV hypoplasia. The mechanism for this association needs further exploration but suggests a role for RV-LV interactions in the development of TR.

Multimodal imaging of the tricuspid valve: normal appearance and pathological entities

The tricuspid valve, which is the atrioventricular valve attached to the morphological right ventricle, is affected by a wide range of pathological processes. Tricuspid valve diseases are now increasingly recognized as a significant cause of morbidity and mortality. Echocardiography is the most widely available and, hence, the first-line imaging modality used in the evaluation of tricuspid valve disorders; however, CT and MRI are also increasingly used for further evaluation and characterization of these entities. In this article, we first review the normal anatomy and embryology of the tricuspid valve, followed by a discussion of the role of multiple imaging modalities in the evaluation of tricuspid valve abnormalities. We then review and illustrate the imaging appearance of several congenital and acquired tricuspid valve abnormalities.

Main Messages

• Tricuspid valve diseases have a significant impact on morbidity and mortality.

• CT and MRI are increasingly used in the evaluation of tricuspid disorders.

• CT and MRI help in diagnosis, functional evaluation, pre-surgical planning and post-surgical follow-up.

• The most common cause of tricuspid regurgitation is functional.

Imaging of Mitral Valve Prolapse: What Can We Learn from Imaging about the Mechanism of the Disease?

Mitral valve prolapse (MVP) is the most common mitral valve disorder affecting 2%-3% of the general population. Two histological forms for the disease exist: Myxomatous degeneration and fibroelastic disease. Pathological evidence suggests the disease is not confined solely to the valve tissue, and accumulation of proteoglycans and fibrotic tissue can be seen in the adjacent myocardium of MVP patients. MVP is diagnosed by demonstrating valve tissue passing the annular line into the left atrium during systole. In this review we will discuss the advantages and limitations of various imaging modalities in their MVP diagnosis ability as well as the potential for demonstrating extra associated valvular pathologies.

Two- and Three-dimensional Transthoracic Echocardiographic Assessment of Tricuspid Valve Prolapse with Mid-to-Late Systolic Tricuspid Regurgitation

We present the two-dimensional echocardiographic findings of tricuspid valve prolapse with mid-to-late systolic tricuspid regurgitation and describe the incremental value provided by live/real time three-dimensional transthoracic echocardiography. We also discuss a potential pitfall when assessing the severity of regurgitation in this setting.

Predictors of outcome of mitral valve prolapse in patients with the Marfan syndrome

Mitral valve prolapse has a prevalence of 2% to 3% in the general population, with adverse outcomes such as mitral valve regurgitation (MVR), heart failure, and endocarditis. Predictors of outcomes are used in idiopathic mitral valve prolapse for the timing of surgery, but such predictors are unknown in Marfan syndrome. Therefore, a population-based cohort study of 112 patients (49 male, 63 female; mean age 34 ± 15 years) with classic Marfan syndrome and mitral valve prolapse with moderate or less MVR at baseline was conducted. During 4.6 ± 3.6 years of follow-up, progression of MVR was observed in 41 patients and valve-related events, which comprised mitral valve endocarditis (7 events), heart failure (5 events), and mitral valve surgery (25 events), were observed in 31 patients. Multivariate Cox proportional-hazards regression analysis identified a flail mitral leaflet (hazard ratio [HR] 3.262, 95% confidence interval [CI] 1.406 to 7.566, p = 0.006) and increased indexed end-systolic left ventricular diameters (HR 1.113, 95% CI 1.043 to 1.188, p = 0.001) as independent predictors of progression of MVR. Similarly, mitral valve-related events were independently predicted by a flail mitral leaflet (HR 5.343, 95% CI 2.229 to 12.808, p <0.001), and mild (HR 14.336, 95% CI 1.873 to 109.755, p = 0.01) or moderate (HR 16.849, 95% CI 2.205 to 128.76, p = 0.006) degree of MVR. Conversely, aortic dilatation, dural ectasia, and sporadic mode of inheritance were not associated with outcome. In conclusion, the same clinical determinants that predict outcomes in idiopathic mitral valve prolapse also predict outcomes in mitral valve prolapse associated with Marfan syndrome.

Frequency and age-related course of mitral valve dysfunction in the Marfan syndrome

Mitral valve (MV) prolapse (MVP) has a high prevalence of 2% to 3% in the general population and thus constitutes the most common cause of severe nonischemic MV regurgitation (MVR). MVP is also common in persons with the Marfan syndrome. However, to date, a large-scale population-based cohort study using modern echocardiographic techniques has not been performed, and the frequency of MVP and the relation of MV dysfunction and age have not been investigated. Therefore, we conducted a population-based cohort study of 204 patients (108 males and 96 females, aged 31.2 ± 16.4 years) with classic Marfan syndrome. We performed echocardiographic follow-up of 174 patients for a mean of 4.4 ± 4.3 years. On the initial or subsequent echocardiographic scan, MVP was present in 82 patients (40%), severe MVR in 25 (12%), and MV endocarditis in 5 patients (2.5%). At 30 years of age, the Weibull cumulative distribution was 42.6% (95% confidence interval [CI] 36% to 50%) for MVP, 56.5% (95% CI 49.3% to 64%) for MVR of any degree, 6.7% (95% CI 3.9% to 11.3%) for severe MVR, and 0.92% (95% CI 0.21% to 3.91%) for MV endocarditis. The cumulative hazard for severe MVR and MV endocarditis was estimated to increase with age. MVP was associated with dural ectasia (p = 0.01), ectopia lentis (p = 0.02), and skeletal involvement (p <0.001). Severe MVR was related to tricuspid valve prolapse (p = 0.002) and to the sporadic form of the Marfan syndrome (p = 0.006). In conclusion, MVP was comparatively frequent in patients with the Marfan syndrome and carries an increased risk of progression to severe MVR and endocarditis, especially in older adults.

Mimics of Ebstein's anomaly

The purpose of this study was to determine the most discriminating clinical and echocardiographic features that are most helpful in correctly identifying Ebstein's anomaly of the tricuspid valve from other causes of tricuspid regurgitation. Ebstein's anomaly is an uncommon malformation of the tricuspid valve with diagnostic echocardiographic features. Other cardiac disorders associated with tricuspid valve regurgitation and predominate right-sided heart chamber enlargement can be misdiagnosed as Ebstein's anomaly. All patients who were referred to our institution between 1982 and 1995 with the diagnosis of Ebstein's anomaly but were found to have other abnormalities of the tricuspid value or right ventricle were identified. Their clinical, echocardiographic, and surgical records were reviewed retrospectively. Twenty-two patients (12 males and 10 females), aged 7 to 68 years (mean 33 years), were referred to our institution with the diagnosis of Ebstein's anomaly but were found to have another abnormality that mimicked clinical and diagnostic features of Ebstein's anomaly. The most common initial symptom was exercise intolerance (13 [59%] patients) followed by atrial arrhythmia (seven [32%] patients). Two patients had cyanosis. Three patients had paroxysmal and six had chronic atrial fibrillation/flutter. Cardiomegaly on chest x-ray film was noted in 18 (82%) patients. Referral diagnosis of Ebstein's anomaly had been made by echocardiography (12 patients), cardiac catheterization (four patients), both techniques (five patients), and echocardiography and magnetic resonance imaging (one patient). All 22 patients had predominate right atrial and right ventricular enlargement, and 18 (82%) of 22 patients also had right ventricular dysfunction. However, Ebstein's anomaly was confidently ruled out with repeat comprehensive echocardiography at our institution by establishing (1) absence of significant apical displacement of the septal tricuspid valve leaflet (> or = 8 mm/m2) and (2) lack of a redundant, elongated, anterior tricuspid valve leaflet in all 22 patients (100%). All had significant tricuspid regurgitation caused by tricuspid valve dysplasia (nine patients), tricuspid valve prolapse (four patients), trauma (four patients), right ventricular dysplasia (three patients), endocarditis (one patient), and annular dilation caused by free pulmonary regurgitation (one patient). In all 15 patients who subsequently underwent surgery (tricuspid valve repair [seven patients] or replacement [eight patients]), the absence of Ebstein's anomaly was confirmed. Echocardiographic absence of the characteristic degree of displacement of the septal leaflet of the tricuspid valve (> or = 8 mm/m2) and the presence of a nonelongated, nonredundant anterior tricuspid valve leaflet consistently excluded the diagnosis of Ebstein's anomaly. Under such circumstances, other anomalies of the tricuspid valve or right ventricle were consistently identified. Recognition of the mimics of Ebstein's anomaly had important surgical implications.

Echocardiographic findings in patients with acquired immunodeficiency syndrome (AIDS) and AIDS-related complex (ARC)

Although a variety of cardiac abnormalities have been described in AIDS patients, it is unclear whether these are incidental findings or they presage clinically important heart disease. Also, because AIDS-related complex (ARC) is, in general, a milder form of AIDS, we wondered if echocardiographic abnormalities would differ in kind or in frequency, when compared with AIDS. To answer these questions, we studied the echocardiographic findings and the demographic features of 15 patients with AIDS and 24 patients with ARC. The ARC group had abnormalities in the same proportion as in our AIDS group, except for echocardiographic mitral valve prolapse. The MVP, however, did not appear to be due to intrinsic valvular disease. Rather, echocardiographic MVP was associated with low body weight (P = .02) but not with the cardiac signs or symptoms of MVP. Four AIDS patients had LV dysfunction. Of the echocardiographic variables, only a wide EPSS was significantly correlated with survival, as it is in other populations. We conclude that although echocardiographic abnormalities are common in AIDS and ARC patients, most of these abnormalities lack clinical significance.