Tricuspid regurgitation and the right ventricle in risk stratification and timing of intervention

Rana, Bushra S.; Robinson, Shaun; Francis, Rajeevan; Toshner, Mark; Swaans, Martin J.; Agarwal, Sharad; Silva, Ravi De; Amer, Radgonde; Nihoyannopoulos, Petros

doi:10.1530/erp-18-0051

Cited by 44 publications

(45 citation statements)

References 71 publications

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“…Intracardiac devices such as catheters and endomyocardial biopsy needles can entangle the TV chordae, impinge on, or perforate leaflets. Pacemaker and defibrillator lead-associated TR is an increasingly recognised phenomenon, with a variety of possible mechanisms ( 11 ). The predominant mechanism is probably direct, lead-associated disruption of TV coaptation, or damage to the leaflets or subvalvar apparatus ( Fig.…”

Section: Causes Of Right-sided Valve Pathologymentioning

confidence: 99%

“…This includes some congenital conditions, for example TV leaflet tethering associated with ventricular septal defects or patches used to close them, causing secondary TR. Right ventricular pacing may promote TR by altering the normal cardiac contraction pattern and creating mechanical dyssynchrony ( 11 ). This might in theory be ameliorated by minimising RV pacing, biventricular pacing, or RV septal lead positioning, although the evidence for this is lacking.…”

Section: Causes Of Right-sided Valve Pathologymentioning

confidence: 99%

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Echocardiographic assessment of the tricuspid and pulmonary valves: a practical guideline from the British Society of Echocardiography

et al. 2020

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Transthoracic echocardiography is the first-line imaging modality in the assessment of right-sided valve disease. The principle objectives of the echocardiographic study are to determine the aetiology, mechanism and severity of valvular dysfunction, as well as consequences on right heart remodelling and estimations of pulmonary artery pressure. Echocardiographic data must be integrated with symptoms, to inform optimal timing and technique of interventions. The most common tricuspid valve abnormality is regurgitation secondary to annular dilatation in the context of atrial fibrillation or left-sided heart disease. Significant pulmonary valve disease is most commonly seen in congenital heart abnormalities. The aetiology and mechanism of tricuspid and pulmonary valve disease can usually be identified by 2-dimensional assessment of leaflet morphology and motion. Colour flow and spectral Doppler are required for assessment of severity, which must integrate data from multiple imaging planes and modalities. Transoesophageal echo is used when transthoracic data is incomplete, although the anterior position of the right heart means that transthoracic imaging is often superior. Three-dimensional echocardiography is a pivotal tool for accurate quantification of right ventricular volumes and regurgitant lesion severity, anatomical characterisation of valve morphology and remodelling pattern, and procedural guidance for catheter-based interventions. Exercise echocardiography may be used to elucidate symptom status and demonstrate functional reserve. CMR and CT should be considered for complimentary data including right ventricular volume quantification, and precise cardiac and extracardiac anatomy. This BSE guideline aims to give practical advice on the standardised acquisition and interpretation of echocardiographic data relating to the pulmonary and tricuspid valves.

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Section: Causes Of Right-sided Valve Pathologymentioning

confidence: 99%

Section: Causes Of Right-sided Valve Pathologymentioning

confidence: 99%

Echocardiographic assessment of the tricuspid and pulmonary valves: a practical guideline from the British Society of Echocardiography

et al. 2020

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“…Secondary effects on right ventricular (RV) function and progressive secondary tricuspid regurgitation (TR) can also be seen. Concomitant primary tricuspid valve disease, while less common, may occur with degenerative or rheumatic valve lesions ( 34 ). Hence it is essential to note RV size, function, TR severity, mechanism and aetiology in addition to PAP estimation ( 1 , 34 ).…”

Section: Mitral Regurgitationmentioning

confidence: 99%

“…Concomitant primary tricuspid valve disease, while less common, may occur with degenerative or rheumatic valve lesions ( 34 ). Hence it is essential to note RV size, function, TR severity, mechanism and aetiology in addition to PAP estimation ( 1 , 34 ).…”

Section: Mitral Regurgitationmentioning

confidence: 99%

The assessment of mitral valve disease: a guideline from the British Society of Echocardiography

Robinson¹,

Ring²,

Augustine³

et al. 2021

Echo Res Pract

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Mitral valve disease is common. Mitral regurgitation is the second most frequent indication for valve surgery in Europe and despite the decline of rheumatic fever in western societies, mitral stenosis of any aetiology is a regular finding in all echo departments. Mitral valve disease is therefore one of the most common pathologies encountered by echocardiographers, as both a primary indication for echocardiography and a secondary finding when investigating other cardiovascular disease processes. Transthoracic and transoesophageal echocardiography (TOE) play a crucial role in the assessment of mitral valve disease and are essential to identifying the aetiology, mechanism and severity of disease and for helping determine the appropriate timing and method of intervention. This guideline, from the British Society of Echocardiography (BSE), describes the assessment of mitral regurgitation and mitral stenosis and replaces previous BSE guidelines describing the echocardiographic assessment of mitral anatomy prior to mitral valve repair surgery and percutaneous mitral valvuloplasty. It provides a comprehensive description of the imaging techniques (and their limitations) employed in the assessment of mitral valve disease. It describes a step-wise approach to identifying: aetiology and mechanism, disease severity, reparability and secondary effects on chamber geometry, function and pressures. Advanced echocardiographic techniques are described for both transthoracic and transoesophageal modalities, including TOE and exercise testing.

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“…To my knowledge, for the evaluation of preoperative RV function, in addition to ejection fraction and pulmonary artery pressure, the detection of deterioration in RV function in an early stage with the myocardial performance index and tricuspid annular plane systolic excursion on echocardiography would have helped with the determination of the exact timing of TV surgery, especially in asymptomatic patients with functional TI. 3 In this regard, the estimation of RV volume on cardiac magnetic resonance imaging could also help with determining which patients would benefit from early TV surgery. 3…”

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confidence: 99%

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Hamandi

Ryan

2020

The Annals of Thoracic Surgery

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I read the article by Hamandi and colleagues 1 with great interest. The authors are to be congratulated for their outstanding contribution to our current knowledge. I have several concerns about the article.In patients undergoing isolated tricuspid valve (TV) surgery, it is essential to separate the patients with endocarditis or congenital TV disease from those with functional tricuspid insufficiency (TI), as progressive dilatation and dysfunction of the right ventricle (RV) develops concomitantly in patients with functional TI. It is given that RV function and the status of end organs are two important preoperative factors dictating early and late outcome after TV surgery. 2 Moreover, the RV tolerates the high-volume state in functional TI by remaining well adapted to maintain the contractility and cardiac output for prolonged periods before progressive RV dilatation, dysfunction, and failure. 3 Therefore, timing of TV surgery is critical, and it relies heavily on the status of the RV, especially in patients with functional TI. Because of the asymptomatic nature of the disease for a long period, serial evaluation of RV function and timely diagnosis of RV dysfunction in its early stage carries the utmost significance in the management of these patients. In the present study, the TV pathology was reported as functional in almost 44% of patients, and almost 62% of patients were in good functional status (New York Heart Association class I and II). The authors had not performed any test to evaluate the RV function; therefore, it is not clear from the article how they judged the exact timing of TV surgery. To my knowledge, for the evaluation of preoperative RV function, in addition to ejection fraction and pulmonary artery pressure, the detection of deterioration in RV function in an early stage with the myocardial performance index and tricuspid annular plane systolic excursion on echocardiography would have helped with the determination of the exact timing of TV surgery, especially in asymptomatic patients with functional TI. 3 In this regard, the estimation of RV volume on cardiac magnetic resonance imaging could also help with determining which patients would benefit from early TV surgery. 3

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Tricuspid regurgitation and the right ventricle in risk stratification and timing of intervention

Cited by 44 publications

References 71 publications

Echocardiographic assessment of the tricuspid and pulmonary valves: a practical guideline from the British Society of Echocardiography

Echocardiographic assessment of the tricuspid and pulmonary valves: a practical guideline from the British Society of Echocardiography

The assessment of mitral valve disease: a guideline from the British Society of Echocardiography

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