tricuspid regurgitation anatomy pathophysiology clinical evaluation management
TRANSCRIPT
TRICUSPID REGURGITATION
• Anatomy
• Pathophysiology
• Clinical
• Evaluation
• Management
TRICUSPID REGURGITATION
TV -- anatomy
Complex apparatus
Largest valve orifice area
TRICUSPID REGURGITATION
Pathophysiology
Primary TR
Secondary TR(functional)
Hypertensive(RVSP > 55 mm Hg)
Normotensive(RVSP < 40 mm Hg)
TR - Pathophysiology
• Primary TR …. Due to structural defects in TV apparatus
• Secondary normotensive TR
• Secondary hypertensive TR
Due to RV and tricuspid annular dilatation
Secondary to elevated RVSP
PAH / RVOT obstruction
Primary TR
Congenital
• isolated TR• Ebstein• AV canal defects• VSD + TR• Hypoplastic RV
Acquired
• rheumatic• prolapse• carcinoid• EMF• endocarditis• tumors• SLE• drugs – methysergide• postop• pacemaker lead
Normotensive functional TR
RV dilatation due to any cause
RV infarctionMyocarditisRV cardiomyopathyUhls anomalyASDFluid overloadHyperdynamic circulation
TRICUSPID REGURGITATION
Clinical features
Secondary TR > symptoms and findings of basic disease
Primary TR
well tolerated till they develop RV failure
• low volume pulse / AF
• JVP - prominent V ;CV (S) wave in severe TR sharp Y descend
• systolic pulsation over liver
TRICUSPID REGURGITATION
Clinical
• cardiomegaly ; RV apex; RA+
• S 1 .. Loud in RHD , ASD , Ebstein
• S2primary TR .. Normal / soft P2
hypertensive TR .. Loud P2 + features of PAH
split of S2 .. Variable
severe TR / no PAH or RVF …early P2
RVF … delayed P2
• RV S3 / S4 / OS / NEC
TRICUSPID REGURGITATION
Clinical
murmurs
Hypertensive TR
loud , high pitched , PSM .. best over LLSB / epigastrium
Normotensive TR
low intensity , soft , early systolicheard well over apex alsodynamic variation is more impressive
increases withinspiration - Carvallo signMuller’s maneuver
TRICUSPID REGURGITATION
ECG . CXR
• findings of underlying disease
• usually in AF
• RV volume / pressure overload pattern
• cardiomegaly with RV / RA / SVC / azygos prominance
• pleural effusion
Depends on the type of TR and its severity
TRICUSPID REGURGITATION
Echocardiogram
• presence of TR
• anatomy of TV apparatus
• etiology of TR
• severity of TR
• hemodynamics .. esp. RVSP
• RV function
• underlying / associated lesions
RVEMF
TR JET
Normotensive TR Hypertensive TR
HEPATIC VEIN FLOW
Normal severe TR
TRICUSPID REGURGITATION
Echo.. Assessment of severity
2 D … RV / RA size ; IVS motion ; dilated vena cava / cor. sinus tricuspid annular diameter
Doppler• jet area
• venacontracta
• PISA
• CW jet configuration
• hepatic vein flow pattern
• IVC pattern
TRICUSPID REGURGITATION
Mild Moderate Severe
Jet area (cm2) < 5 5 -10 > 10
Vena contr. Not defined not defined > 0.70 cm(but < 0.70 cm)
PISA dia (cm) < 0.5 0.5 – 0.9 > 0.9
CW jet soft / parabolic dense / densevariable shape triangular
early peak
Hepatic normal systolic blunting systolic reversalVein flow
IVC size < 15 mm 15 -20 mm > 20 mm respirophasic normal normal absent
mild blunting
TRICUSPID REGURGITATIOM
RV function
• RV fractional area changeRV area (d) – RV area (s)
Normal .. 35 – 65 %RV area (d)
• TAPSE … 15 – 30 mm
• TDI … annular velocity … 6 -14 cm / s
• MPI (PWD) .. 0.15 – 0.40
• RVEF .. 45 – 70 %
TRICUSPID REGURGITATION
CMR
Limited role
To assess anatomy , RV function
TRICUSPID REGURGITATION
Staging of TR
Stage A at risk of TRclinically normal / normal hemodynamicsECG / CXR – normalEcho .. early / mild anatomical changes no / trace TR
Stage B progressive TRmild / moderate TRprogressive anatomic changes ( not severe)asymptomatic
Stage C asymptomatic severe TRgross anatomical deformitysevere annular dilatation ( > 21 mm / m2 or > 40 mm)
Stage D symptomatic severe TR( stage C + symptoms)
TRICUSPID REGURGITATION
Management
• treatment of underlying disease
• control of CHF / heart rate in AF / anticoagulation SOS
Stage C / D consider surgery
Secondary TR …. Tricuspid annuloplasty
Suture(unsupported)
Ring
Primary TR …. TVR (bioprosthesis)
TR in IE .. If infection is not controlled .. consider surgery
total excision of TV … bioprosthesis after 6 – 9 months