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Afilalo J, Grapsa J, Nihoyannopoulos P, Beaudoin J, Gibbs JSR, Channick RN, Langleben D, Rudski LG, Hua L, Handschumacher MD, Picard MH, Levine RA. Leaflet area as a determinant of tricuspid regurgitation severity in patients with pulmonary hypertension. Circ Cardiovasc Imaging 2015; 8:CIRCIMAGING.114.002714. [PMID: 25977303 DOI: 10.1161/circimaging.114.002714] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Tricuspid regurgitation (TR) is a risk factor for mortality in pulmonary hypertension (PH). TR severity varies among patients with comparable degrees of PH and right ventricular remodeling. The contribution of leaflet adaptation to the pathophysiology of TR has yet to be examined. We hypothesized that tricuspid leaflet area (TLA) is increased in PH, and that the adequacy of this increase relative to right ventricular remodeling determines TR severity. METHODS AND RESULTS A prospective cohort of 255 patients with PH from pre and postcapillary pathogeneses was assembled from 2 centers. Patients underwent a 3-dimensional echocardiogram focused on the tricuspid apparatus. TLA was measured with the Omni 4D software package. Compared with normal controls, patients with PH had a 2-fold increase in right ventricular volumes, 62% increase in annular area, and 49% increase in TLA. Those with severe TR demonstrated inadequate increase in TLA relative to the closure area, such that the ratio of TLA:closure area <1.78 was highly predictive of severe TR (odds ratio, 68.7; 95% confidence interval, 16.2-292.7). The median vena contracta width was 8.5 mm in the group with small TLA and large closure area as opposed to 4.8 mm in the group with large TLA and large closure area. CONCLUSIONS TLA plays a significant role in determining which patients with PH develop severe functional TR. The ratio of TLA:closure area, reflecting the balance between leaflet adaptation versus annular dilation and tethering forces, is an indicator of TR severity that may identify which patients stand to benefit from leaflet augmentation during tricuspid valve repair.
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Affiliation(s)
- Jonathan Afilalo
- From the Division of Cardiology, Jewish General Hospital, McGill University, Montreal, Canada (J.A., D.L., L.G.R.); Cardiac Ultrasound Laboratory, Division of Cardiology (J.G., P.N.) and National Pulmonary Hypertension Service, Division of Cardiology (J.S.R.G.), Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom; Pulmonary Hypertension and Thromboendarterectomy Program, Division of Pulmonary and Critical Care Medicine (R.N.C.) and Cardiac Ultrasound Laboratory, Division of Cardiology (J.A., J.B., L.H., M.D.H., M.H.P., R.A.L.), Massachusetts General Hospital, Harvard University, Boston.
| | - Julia Grapsa
- From the Division of Cardiology, Jewish General Hospital, McGill University, Montreal, Canada (J.A., D.L., L.G.R.); Cardiac Ultrasound Laboratory, Division of Cardiology (J.G., P.N.) and National Pulmonary Hypertension Service, Division of Cardiology (J.S.R.G.), Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom; Pulmonary Hypertension and Thromboendarterectomy Program, Division of Pulmonary and Critical Care Medicine (R.N.C.) and Cardiac Ultrasound Laboratory, Division of Cardiology (J.A., J.B., L.H., M.D.H., M.H.P., R.A.L.), Massachusetts General Hospital, Harvard University, Boston
| | - Petros Nihoyannopoulos
- From the Division of Cardiology, Jewish General Hospital, McGill University, Montreal, Canada (J.A., D.L., L.G.R.); Cardiac Ultrasound Laboratory, Division of Cardiology (J.G., P.N.) and National Pulmonary Hypertension Service, Division of Cardiology (J.S.R.G.), Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom; Pulmonary Hypertension and Thromboendarterectomy Program, Division of Pulmonary and Critical Care Medicine (R.N.C.) and Cardiac Ultrasound Laboratory, Division of Cardiology (J.A., J.B., L.H., M.D.H., M.H.P., R.A.L.), Massachusetts General Hospital, Harvard University, Boston
| | - Jonathan Beaudoin
- From the Division of Cardiology, Jewish General Hospital, McGill University, Montreal, Canada (J.A., D.L., L.G.R.); Cardiac Ultrasound Laboratory, Division of Cardiology (J.G., P.N.) and National Pulmonary Hypertension Service, Division of Cardiology (J.S.R.G.), Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom; Pulmonary Hypertension and Thromboendarterectomy Program, Division of Pulmonary and Critical Care Medicine (R.N.C.) and Cardiac Ultrasound Laboratory, Division of Cardiology (J.A., J.B., L.H., M.D.H., M.H.P., R.A.L.), Massachusetts General Hospital, Harvard University, Boston
| | - J Simon R Gibbs
- From the Division of Cardiology, Jewish General Hospital, McGill University, Montreal, Canada (J.A., D.L., L.G.R.); Cardiac Ultrasound Laboratory, Division of Cardiology (J.G., P.N.) and National Pulmonary Hypertension Service, Division of Cardiology (J.S.R.G.), Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom; Pulmonary Hypertension and Thromboendarterectomy Program, Division of Pulmonary and Critical Care Medicine (R.N.C.) and Cardiac Ultrasound Laboratory, Division of Cardiology (J.A., J.B., L.H., M.D.H., M.H.P., R.A.L.), Massachusetts General Hospital, Harvard University, Boston
| | - Richard N Channick
- From the Division of Cardiology, Jewish General Hospital, McGill University, Montreal, Canada (J.A., D.L., L.G.R.); Cardiac Ultrasound Laboratory, Division of Cardiology (J.G., P.N.) and National Pulmonary Hypertension Service, Division of Cardiology (J.S.R.G.), Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom; Pulmonary Hypertension and Thromboendarterectomy Program, Division of Pulmonary and Critical Care Medicine (R.N.C.) and Cardiac Ultrasound Laboratory, Division of Cardiology (J.A., J.B., L.H., M.D.H., M.H.P., R.A.L.), Massachusetts General Hospital, Harvard University, Boston
| | - David Langleben
- From the Division of Cardiology, Jewish General Hospital, McGill University, Montreal, Canada (J.A., D.L., L.G.R.); Cardiac Ultrasound Laboratory, Division of Cardiology (J.G., P.N.) and National Pulmonary Hypertension Service, Division of Cardiology (J.S.R.G.), Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom; Pulmonary Hypertension and Thromboendarterectomy Program, Division of Pulmonary and Critical Care Medicine (R.N.C.) and Cardiac Ultrasound Laboratory, Division of Cardiology (J.A., J.B., L.H., M.D.H., M.H.P., R.A.L.), Massachusetts General Hospital, Harvard University, Boston
| | - Lawrence G Rudski
- From the Division of Cardiology, Jewish General Hospital, McGill University, Montreal, Canada (J.A., D.L., L.G.R.); Cardiac Ultrasound Laboratory, Division of Cardiology (J.G., P.N.) and National Pulmonary Hypertension Service, Division of Cardiology (J.S.R.G.), Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom; Pulmonary Hypertension and Thromboendarterectomy Program, Division of Pulmonary and Critical Care Medicine (R.N.C.) and Cardiac Ultrasound Laboratory, Division of Cardiology (J.A., J.B., L.H., M.D.H., M.H.P., R.A.L.), Massachusetts General Hospital, Harvard University, Boston
| | - Lanqi Hua
- From the Division of Cardiology, Jewish General Hospital, McGill University, Montreal, Canada (J.A., D.L., L.G.R.); Cardiac Ultrasound Laboratory, Division of Cardiology (J.G., P.N.) and National Pulmonary Hypertension Service, Division of Cardiology (J.S.R.G.), Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom; Pulmonary Hypertension and Thromboendarterectomy Program, Division of Pulmonary and Critical Care Medicine (R.N.C.) and Cardiac Ultrasound Laboratory, Division of Cardiology (J.A., J.B., L.H., M.D.H., M.H.P., R.A.L.), Massachusetts General Hospital, Harvard University, Boston
| | - Mark D Handschumacher
- From the Division of Cardiology, Jewish General Hospital, McGill University, Montreal, Canada (J.A., D.L., L.G.R.); Cardiac Ultrasound Laboratory, Division of Cardiology (J.G., P.N.) and National Pulmonary Hypertension Service, Division of Cardiology (J.S.R.G.), Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom; Pulmonary Hypertension and Thromboendarterectomy Program, Division of Pulmonary and Critical Care Medicine (R.N.C.) and Cardiac Ultrasound Laboratory, Division of Cardiology (J.A., J.B., L.H., M.D.H., M.H.P., R.A.L.), Massachusetts General Hospital, Harvard University, Boston
| | - Michael H Picard
- From the Division of Cardiology, Jewish General Hospital, McGill University, Montreal, Canada (J.A., D.L., L.G.R.); Cardiac Ultrasound Laboratory, Division of Cardiology (J.G., P.N.) and National Pulmonary Hypertension Service, Division of Cardiology (J.S.R.G.), Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom; Pulmonary Hypertension and Thromboendarterectomy Program, Division of Pulmonary and Critical Care Medicine (R.N.C.) and Cardiac Ultrasound Laboratory, Division of Cardiology (J.A., J.B., L.H., M.D.H., M.H.P., R.A.L.), Massachusetts General Hospital, Harvard University, Boston
| | - Robert A Levine
- From the Division of Cardiology, Jewish General Hospital, McGill University, Montreal, Canada (J.A., D.L., L.G.R.); Cardiac Ultrasound Laboratory, Division of Cardiology (J.G., P.N.) and National Pulmonary Hypertension Service, Division of Cardiology (J.S.R.G.), Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom; Pulmonary Hypertension and Thromboendarterectomy Program, Division of Pulmonary and Critical Care Medicine (R.N.C.) and Cardiac Ultrasound Laboratory, Division of Cardiology (J.A., J.B., L.H., M.D.H., M.H.P., R.A.L.), Massachusetts General Hospital, Harvard University, Boston
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Afilalo J, Grapsa J, Nihoyannopoulos P, Beaudoin J, Gibbs JSR, Channick RN, Langleben D, Rudski LG, Hua L, Handschumacher MD, Picard MH, Levine RA. Leaflet Area as a Determinant of Tricuspid Regurgitation Severity in Patients With Pulmonary Hypertension. Circ Cardiovasc Imaging 2015. [DOI: 10.1161/circimaging.114.002714 e002714] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/08/2023]
Abstract
Background—
Tricuspid regurgitation (TR) is a risk factor for mortality in pulmonary hypertension (PH). TR severity varies among patients with comparable degrees of PH and right ventricular remodeling. The contribution of leaflet adaptation to the pathophysiology of TR has yet to be examined. We hypothesized that tricuspid leaflet area (TLA) is increased in PH, and that the adequacy of this increase relative to right ventricular remodeling determines TR severity.
Methods and Results—
A prospective cohort of 255 patients with PH from pre and postcapillary pathogeneses was assembled from 2 centers. Patients underwent a 3-dimensional echocardiogram focused on the tricuspid apparatus. TLA was measured with the Omni 4D software package. Compared with normal controls, patients with PH had a 2-fold increase in right ventricular volumes, 62% increase in annular area, and 49% increase in TLA. Those with severe TR demonstrated inadequate increase in TLA relative to the closure area, such that the ratio of TLA:closure area <1.78 was highly predictive of severe TR (odds ratio, 68.7; 95% confidence interval, 16.2–292.7). The median vena contracta width was 8.5 mm in the group with small TLA and large closure area as opposed to 4.8 mm in the group with large TLA and large closure area.
Conclusions—
TLA plays a significant role in determining which patients with PH develop severe functional TR. The ratio of TLA:closure area, reflecting the balance between leaflet adaptation versus annular dilation and tethering forces, is an indicator of TR severity that may identify which patients stand to benefit from leaflet augmentation during tricuspid valve repair.
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Affiliation(s)
- Jonathan Afilalo
- From the Division of Cardiology, Jewish General Hospital, McGill University, Montreal, Canada (J.A., D.L., L.G.R.); Cardiac Ultrasound Laboratory, Division of Cardiology (J.G., P.N.) and National Pulmonary Hypertension Service, Division of Cardiology (J.S.R.G.), Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom; Pulmonary Hypertension and Thromboendarterectomy Program, Division of Pulmonary and Critical Care Medicine (R.N.C.) and Cardiac Ultrasound Laboratory,
| | - Julia Grapsa
- From the Division of Cardiology, Jewish General Hospital, McGill University, Montreal, Canada (J.A., D.L., L.G.R.); Cardiac Ultrasound Laboratory, Division of Cardiology (J.G., P.N.) and National Pulmonary Hypertension Service, Division of Cardiology (J.S.R.G.), Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom; Pulmonary Hypertension and Thromboendarterectomy Program, Division of Pulmonary and Critical Care Medicine (R.N.C.) and Cardiac Ultrasound Laboratory,
| | - Petros Nihoyannopoulos
- From the Division of Cardiology, Jewish General Hospital, McGill University, Montreal, Canada (J.A., D.L., L.G.R.); Cardiac Ultrasound Laboratory, Division of Cardiology (J.G., P.N.) and National Pulmonary Hypertension Service, Division of Cardiology (J.S.R.G.), Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom; Pulmonary Hypertension and Thromboendarterectomy Program, Division of Pulmonary and Critical Care Medicine (R.N.C.) and Cardiac Ultrasound Laboratory,
| | - Jonathan Beaudoin
- From the Division of Cardiology, Jewish General Hospital, McGill University, Montreal, Canada (J.A., D.L., L.G.R.); Cardiac Ultrasound Laboratory, Division of Cardiology (J.G., P.N.) and National Pulmonary Hypertension Service, Division of Cardiology (J.S.R.G.), Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom; Pulmonary Hypertension and Thromboendarterectomy Program, Division of Pulmonary and Critical Care Medicine (R.N.C.) and Cardiac Ultrasound Laboratory,
| | - J. Simon R. Gibbs
- From the Division of Cardiology, Jewish General Hospital, McGill University, Montreal, Canada (J.A., D.L., L.G.R.); Cardiac Ultrasound Laboratory, Division of Cardiology (J.G., P.N.) and National Pulmonary Hypertension Service, Division of Cardiology (J.S.R.G.), Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom; Pulmonary Hypertension and Thromboendarterectomy Program, Division of Pulmonary and Critical Care Medicine (R.N.C.) and Cardiac Ultrasound Laboratory,
| | - Richard N. Channick
- From the Division of Cardiology, Jewish General Hospital, McGill University, Montreal, Canada (J.A., D.L., L.G.R.); Cardiac Ultrasound Laboratory, Division of Cardiology (J.G., P.N.) and National Pulmonary Hypertension Service, Division of Cardiology (J.S.R.G.), Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom; Pulmonary Hypertension and Thromboendarterectomy Program, Division of Pulmonary and Critical Care Medicine (R.N.C.) and Cardiac Ultrasound Laboratory,
| | - David Langleben
- From the Division of Cardiology, Jewish General Hospital, McGill University, Montreal, Canada (J.A., D.L., L.G.R.); Cardiac Ultrasound Laboratory, Division of Cardiology (J.G., P.N.) and National Pulmonary Hypertension Service, Division of Cardiology (J.S.R.G.), Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom; Pulmonary Hypertension and Thromboendarterectomy Program, Division of Pulmonary and Critical Care Medicine (R.N.C.) and Cardiac Ultrasound Laboratory,
| | - Lawrence G. Rudski
- From the Division of Cardiology, Jewish General Hospital, McGill University, Montreal, Canada (J.A., D.L., L.G.R.); Cardiac Ultrasound Laboratory, Division of Cardiology (J.G., P.N.) and National Pulmonary Hypertension Service, Division of Cardiology (J.S.R.G.), Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom; Pulmonary Hypertension and Thromboendarterectomy Program, Division of Pulmonary and Critical Care Medicine (R.N.C.) and Cardiac Ultrasound Laboratory,
| | - Lanqi Hua
- From the Division of Cardiology, Jewish General Hospital, McGill University, Montreal, Canada (J.A., D.L., L.G.R.); Cardiac Ultrasound Laboratory, Division of Cardiology (J.G., P.N.) and National Pulmonary Hypertension Service, Division of Cardiology (J.S.R.G.), Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom; Pulmonary Hypertension and Thromboendarterectomy Program, Division of Pulmonary and Critical Care Medicine (R.N.C.) and Cardiac Ultrasound Laboratory,
| | - Mark D. Handschumacher
- From the Division of Cardiology, Jewish General Hospital, McGill University, Montreal, Canada (J.A., D.L., L.G.R.); Cardiac Ultrasound Laboratory, Division of Cardiology (J.G., P.N.) and National Pulmonary Hypertension Service, Division of Cardiology (J.S.R.G.), Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom; Pulmonary Hypertension and Thromboendarterectomy Program, Division of Pulmonary and Critical Care Medicine (R.N.C.) and Cardiac Ultrasound Laboratory,
| | - Michael H. Picard
- From the Division of Cardiology, Jewish General Hospital, McGill University, Montreal, Canada (J.A., D.L., L.G.R.); Cardiac Ultrasound Laboratory, Division of Cardiology (J.G., P.N.) and National Pulmonary Hypertension Service, Division of Cardiology (J.S.R.G.), Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom; Pulmonary Hypertension and Thromboendarterectomy Program, Division of Pulmonary and Critical Care Medicine (R.N.C.) and Cardiac Ultrasound Laboratory,
| | - Robert A. Levine
- From the Division of Cardiology, Jewish General Hospital, McGill University, Montreal, Canada (J.A., D.L., L.G.R.); Cardiac Ultrasound Laboratory, Division of Cardiology (J.G., P.N.) and National Pulmonary Hypertension Service, Division of Cardiology (J.S.R.G.), Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom; Pulmonary Hypertension and Thromboendarterectomy Program, Division of Pulmonary and Critical Care Medicine (R.N.C.) and Cardiac Ultrasound Laboratory,
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