Dr.Gökhan Kahveci

1. Dr.Gökhan Kahveci Preoperative echocardiographic clues for the repair of tricuspid valve and assessment of right ventricular functions

2. SecondaryTricuspidRegurgitation • Functional or secondary tricuspid regurgitation (STR) is the most frequent etiology of tricuspid valve pathology Don’tTouch Aggressivesurgicalapproach

3. SecondaryTricuspidRegurgitation • Functional or secondary tricuspid regurgitation (STR) refersto tricuspid regurgitation (TR) occurring secondary toleft-sided heart disease or pulmonary hypertensionin the absence of organic lesions of the tricuspid valve (TV)apparatus

4. SecondaryTricuspidRegurgitation TR would disappear once the primary LHD had beentreated??? stillinfluencessurgicalpractice today TV repair remains an all too infrequent procedure at most surgical centers Taramasso M-JACC-2012

5. STR-Prognosis Kwak JJ ,AHJ-2008

6. TV Anatomy • Tricuspid orifice is larger (6-7 cm² and • more triangular (accordingto mitral ann.) • Tricuspid • annulus has an elliptic, nonplanar shape.

7. Pathophysiology ofSecondaryTricuspidRegurgitation • Most common etiology of STR: RV dilation and dysfunction from LHD • The pathophysiology of STR may be divided into 3phases: 1.Dilation of therightventricleresults in TA dilation 2.Progressive RV and TA dilation,failure of leafletcoaptation, andsignificant STR 3.Progressive RV distortionand eccentricity, tethering of the leaflets

8. SecondaryTricuspidRegurgitation • Significanttricuspidannulardilatationis defined by a diastolic diameter ≥40 mm or ≥21 mm/m² in the four-chamber transthoracic view. • Significanttethering coaptation distance >8 mm ESC 2012 VHD-Guidelines

9. Theprevalence of STR • Degenerative mitral regurgitation30% of patientshave TR ≥2+ at the time of mitral surgery • Rheumatic mitral stenosis 30% of patientshave TR ≥2+ • ischemic mitral regurgitation 30% of patientshave TR

10. Late TR • Significant TR occurring late after left-heart surgery isobserved in up to 40% of patients, with a median survival of5 years. • TV annuloplasty during mitral surgery results in a lower incidence of late TR.

11. TR-Echocardiography • 2D Echo has the inherent limitation ofnot being able to show all three tricuspid leaflets together in thesameview • Realtime3D Echo (RT-3DE) has the unique capability of obtaining ashort-axis plane of the TV

12. TR Quantification-EACI 2013 • Normal tricuspidvalveannulus diameter in adults is 28+5 mm in the four-chamber view (in diastole) Average TA circumference is 78 ± 7 mm/m² • Significant tricuspid annular dilatation is defined by a diastolic diameterof ≥21 mm/m² (>35 mm) • Tentingarea >1 cm² is related severe TR

13. TR Quantification-EACI 2013 ColourFlowImaging The colour flow area of the regurgitant jet isnot recommended to quantify the severity of TR. Thecolour flow imaging should only be used for diagnosing TR.

14. TR Quantification-EACI 2013 VC width ≥7 mm defines severe TR. Poor accuracy of the in eccentricjets 3D EROA >75 mm²  severe TR (needvalidation)

15. TR Quantification-EACI 2013 Flowconvergencemethod (PISA) • EROA ≥40 mm² or • RVol of ≥45 mLindicates severe TR. Quantitative but haveseverallimitations-underestimatesseverityby 30%

16. TR Quantification-EACI 2013 • PeaktricuspidinflowE velocity >1 m/s suggests severe TR • The systolic hepatic flow reversal is specific forsevere TR. It represents the strongest additional parameterfor evaluating the severity of TR.

17. TR Quantification-EACI 2013 Lancellotti P-EHJ-2013

18. RT3DE • The ability to visualize all three tricuspid leafletssimultaneously is a major advantage of RT3DE. • In TR patients, the tricuspid annulus tends to dilate in the septal-lateral andposteroseptal-to-anterolateral dimensions, resulting in a more circular and planar shape compared with healthy controls

19. 3D-TEE • RT-3D TEE data to describe the tricuspid annulus. • Eccentric dilation seen in patients with TR. • The tricuspid annulus shape is complex, with annular high and low points, and annular area calculation based on linear measurements significantly overestimates 3D planimetered area

20. Predictors of Unsuccessful TV Repair • Preop RV dysfunction • Severe TR • Severe TV tethering Tentingarea>1.63 cm² Tentingdistance>0.76 cm • Higherpulmonaryarterypressures • Increased LV remodeling • Sutureannuloplasty (De vega) • Larger ring size • MV replacement rather than repair • Presence of pacemakerleads

21. Predictors of Late TR After Mitral Repair TricuspidAnulus>70 mm at the surgical table or of >40 mm or 21 mm/m² at theechoimaging Katsi V-ICTS-2012 Dreyfus GD-Heart 2009

22. Echocardiography and Surgical Technique • Ring annuloplasty should be performed in thepresence of isolated annular dilatation. • Conversely, when severe annular dilatation and leaflet tethering are present, pericardialpatch augmentation of the anteriorleaflet or replacement of the TV should be considered.

23. ESC-2012-VHD • Predictingthe evolution of functional TR after surgical treatment of mitral valvediseaseremainsdifficult. Pulmonaryhypertension, increased RV pressure and dimension, reduced RV function, AF,pacemaker leads, and the severity of tricuspid valve deformation(tricuspid annulus diameter, coaptation height) are important riskfactors for persistence or late worsening of TR.

24. ESC2012-VHD • Ring annuloplastyis key to surgery for TR. Better long-term resultsare observed with prosthetic rings than with the suture annuloplasty, • The incidence of residual TR being, respectively, 10%vs20–35% at 5 years.

25. IndicationsforTricuspidValveSurgery Severe RightVentricular Dysfunction???? ESC 2012 VHD-Guidelines

26. Indications for Tricuspid Valve Surgery If secondary TR is less than severe, thediameter of the tricuspid annulus ratherthan the grade of regurgitation (which ishighly subjective and variable) should bethe criterion to indicate the need for concomitantTV repair at the time of mitral valve (MV) surgery

27. Assessment of RV Function The echocardiographic quantitative assessment of right ventricular (RV) function has been difficult owing to the complex RV anatomy. Identifying an accurate and reliable echocardiographic parameter for the functional assessment of the RV still remains a challenge

28. Assessment of RV Function • It has a complex geometry, appearing triangular whenviewed from the front, and crescentic when viewed in a transverse section of the heart • Cannot be fitted to simple geometric models Limitation of 2D

29. Essential Imaging Windows and Views-1

30. Essential Imaging Windows and Views-2

31. Essential Imaging Windows and Views-3

32. Essential Imaging Windows and Views-4

33. Essential Imaging Windows and Views-5

34. Essential Imaging Windows and Views-6

35. Right Heart Dimensions ASE 2010

36. RightVentricleDimensions Thesensitivity of right ventricular sizewithangular change Ensure that the RVis not foreshortened and that the LVoutflow tract is not opened up (avoid the apical 5-chamber view)

37. RV Dimensions RV basal dimension <42 mm (RVD1)

38. RVOT Dimensions RVOT proximal diameter <33 mm RVOT proximal diameter <27mm

39. RV Systolic Function-FAC RV FAC = EDA-ESA/EDAX100 RV FAC <35% Prognostic value + Correlation with MRI derived EF

40. RV Systolic Function-2D RVEF 2DRV EF is not recommended, because of the heterogeneityof methods and the numerous geometric assumptions ASE 2010

41. RV Systolic Function-3D RVEF • Three-Dimensional Volume Estimation • RV end-diastolic volume <89 mL/m² • RV end-systolic volume <45 mL/m² (10% to 15% lower in women) The lowerreference limit for RV EF is 44% Excellent correlation with MRI derived EF

42. RV Systolic Function-3D RVEF

43. RV MPI MPI = IVRT+IVCT/ET TissueDoppler derived MPI >0.55 RV dysfunction

44. TAPSE TAPSE may not reflect whole RV systolic function <16 mm RV dysf. Correlation with isotropic derived RVEF Prognostic value in HF

45. Doppler Tissue Imaging Cut-off value of 11.5 cm/sfor tricuspid ring systolic velocities is able to accurately predictglobal RV dysfunction (defined as RVEF <45%).

46. Myocardial Acceleration During Isovolumic Contraction IVA measured in the basalsegment of the RV free wall of > 1.1 m/s2 correlates well withMRI RVEF >45% (90% sensitivity and specificity). Angle dependent Load independent

47. RV Strain and Strain Rate (STE) StrainPercentage change in myocardial deformation Strain rate rate of deformation of myocardium over time • Reflect regional and global RV functions • Less load dependent

48. RV Strain and Strain Rate (STE)

49. LV eccentricity index (EccIx) • EccIx, defined asthe ratio of the LV antero-posterior to septo-lateral diameters in a short-axis view • EccIx >1 at end-diastole  volume overload • Ecclx>1 at end systole and diastole pressure overload

50. ASE-Right Heart Evaulation • Examinethe right heart using multiple acoustic windows • Report should representqualitativeandquantitativeparameters. RV size RA size RV systolicfunction (at least one of the following): Fractional areachange [FAC] TAPSE S` SPAP