Changes in Tricuspid Annular Geometry in Patients with Functional Tricuspid Regurgitation

Comprehensive Dynamic 3-Dimensional Analysis of the Tricuspid Valve in Functional Tricuspid Regurgitation: Implications for Prophylactic Tricuspid Valve Intervention

OBJECTIVES

To track and measure changes in the tricuspid annulus (TA) using 3-dimensional (3D) echocardiography during a complete cardiac cycle in patients with functional tricuspid regurgitation (TR) compared to patients without TR, and to compare tricuspid annular plane systolic excursion (TAPSE) derived from 2-dimensional (2D) and 3D coordinates as a measure of right ventricular (RV) function to the standard method of 2D fractional area change (FAC).

DESIGN

Intraoperative 3D echocardiography data were collected prospectively, followed by postprocessing software analysis to track and reconstruct changes throughout the cardiac cycle.

SETTING

Data were collected from 108 patients undergoing left-sided heart surgery at 2 large academic centers-Beth Israel Deaconess Medical Center in Boston, MA and Rhode Island Hospital, Providence, RI-between November 2018 and April 2020.

PARTICIPANTS

The final dataset (n = 92) included 2 groups: the no significant functional TR (NTR) group (n = 74), defined as ≤ mild TR and TA <35 mm, and the significant functional TR (FTR) group (n = 18), defined as ≥ moderate TR.

INTERVENTIONS

3D TEE datasets were analyzed, and the motion of TA coordinates was tracked during complete cardiac cycle in 2D and 3D planes using postprocessing and software analysis. Computational modeling of TA motion was performed using computer-aided design. In further analysis, reconstructed and 3D printed models of TV were developed for the 2 groups.

MEASUREMENTS AND MAIN RESULTS

`Patients in FTR group had larger TA size during the cardiac cycle, with less overall excursion and reduced annular dynamism. The 3D motion of TA for lateral, anterolateral, and posterolateral coordinates was lower in the FTR group compared to the NTR group [18 ± 6.8 vs 13.6 ± 8.5( p = 0.02); 15.2 ± 5.5 vs 11.3 ± 6.0 (p = 0.009); and 17.6 ± 6.6 vs 12.3 ± 5.2 (p = 0.002), respectively]. TAPSE derived from 3D planes was more accurate for RV function assessment when comapred with 2D FAC (area under the curve [AUC], 0.704; p = 0.011) than 2D TAPSE (AUC, 0.625; p = 0.129). Finally, in the FTR group, the anteroseptal-posterolateral diameter was consistently larger during all phases of the cardiac cycle compared to the conventionally measured septolateral diameter.

CONCLUSIONS

3D echocardiographic assessment of TA helps better understand its geometry and dynamism in functional TR and is more accurate than 2D measurements for RV function assessment.

Different Causes of Functional Tricuspid Valve Regurgitation Are Linked to Differences in Tricuspid Valve and Right-Sided Heart Geometry and Function: 3D Echocardiography Study

Background and Objectives: The aim of this study was to clarify the tricuspid valve (TV) and right ventricular (RV) geometry and function characteristics using 3D echocardiography-based analysis and to identify echocardiographic predictors for severe tricuspid regurgitation (TR) in different etiologies of functional TR (fTR). Methods and Results: The prospective study included 128 patients (median age 64 years, 57% females): 109 patients with moderate or severe fTR (69-caused by dominant left-sided valvular pathology (LSVP), 40 due to precapillary pulmonary hypertension (PH)), and 19 healthy controls. The 2D and 3D-transthoracic echocardiography analysis included TV, right atrium, RV geometry, and functional parameters. All the RV geometry parameters as well as 3D TV parameters were increased in both fTR groups when compared to controls. Higher RV diameters, length, areas, volumes, and more impaired RV function were in PH group compared to LSVP group. PH was associated with larger leaflet tenting height, volume, and more increased indices of septal-lateral and major axis tricuspid annulus (TA) diameters. LVSP etiology was associated with higher anterior-posterior TA diameter and sphericity index. Univariate and multivariate logistic regression and ROC analyses revealed that different fTR etiologies were associated with various 2D and 3D echocardiographic parameters to predict severe TR: major axis TA diameter and TA perimeter, the leaflet tenting volume had the highest predictive value in PH group, septal-lateral systolic TA diameter-in LSVP group. The 3D TA analysis provided more reliable prediction for severe fTR. Conclusions: TV and RV geometry vary in different etiologies of functional TR. Precapillary PH is related to more severe RV remodeling and dysfunction and changes of TV geometry, when compared to LSVP group. The 3D echocardiography helps to determine echocardiographic predictors of severe TR in different fTR etiologies.

Functional tricuspid regurgitation, related right heart remodeling, and available treatment options: good news for patients with heart failure?

Significant functional tricuspid regurgitation (FTR) represents a poor prognostic factor independent of right ventricular (RV) function. It is usually the consequence of left-sided cardiac diseases that induce RV dilatation and dysfunction, but it can also resulted from right atrial (RA) enlargement and consequent tricuspid annular dilatation. FTR is very frequent among patients with heart failure, particularly in those with reduced LVEF and concomitant functional mitral regurgitation. The development of three-dimensional echocardiography enabled detailed assessment of tricuspid valve anatomy, subvavlular apparatus, and RA and RV changes, as well as accurate evaluation of FTR etiology. Due to high in-hospital mortality risk in patients who were operatively treated for isolated FTR, it has been treated only medically for a long time. Percutaneous approach considers mainly transcatheter tricuspid valve repair (edge-to-edge and annuloplasty) and represents a very attractive option for the high-risk patients. Studies that investigated the effects of different devices showed excellent feasibility and safety, followed by significant reduction in FTR grade, improvement in functional capacity and NYHA class, quality of life, and reduction in hospitalization due to heart failure. Some investigations also reported a decreased mortality in FTR patients. Nevertheless, the results of these investigations should be interpreted with cautious due to the small number of participants and relatively short follow-up. The aim of this review was to summarize the existing data about the clinical importance of FTR and FTR-induced right heart remodeling and currently existing therapeutic approaches for treatment of FTR.

Specific Anatomic Considerations for Tricuspid Interventions

PURPOSE OF REVIEW

This review discusses the normal anatomy and pathology of the tricuspid valve (TV) and right side of the heart. Emphasis is on those anatomic and pathologic features relevant to interventions intended to restore normal function to the TV in disease states.

RECENT FINDINGS

TV pathology is less common than aortic and mitral valve pathology, and treatment and outcomes for interventions face considerable hurdles. New innovations and early data showing safety and efficacy in transcatheter interventions have transformed TV interventions into the next frontier in cardiac valve disease treatment. Certain features of the TV and right heart have presented themselves as potential targets, as well as impediments, for TV intervention. The causes of TV pathology and the anatomy of the TV and right heart bring unique challenges to intervention. Approaches to intervention will continue to progress and change the way we view and treat TV pathology.

Functional Tricuspid Regurgitation in Mitral Valve Disease

Functional tricuspid regurgitation is a common finding in patients with left-sided heart disease. If left untreated, it may reduce survival, limit functional capacity and cause end-organ dysfunction. Annulus dilation and leaflet tethering due to right ventricle remodeling are 2 major pathophysiologic mechanisms in functional tricuspid regurgitation. Even if surgical treatment remains the gold standard, indication and timing of surgical interventions remain the object of debate in the medical community. More recently, numerous transcatheter therapies have been developed in order to offer less invasive options to patients who otherwise would have a high risk of mortality and morbidity with surgical interventions.