An Integrative, Multiparametric Approach to Tricuspid Regurgitation Evaluation

Figures

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  Figure 1. Case 1: Example of Quantitative Measurement of TR Shown are the measurements of regurgitant flow using the flow convergence method and peak velocity using continuous-wave Doppler with calculation of ERO and regurgitant volume. ERO = effective regurgitant orifice; TR = tricuspid regurgitation.

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  Figure 2. Hemodynamics With Severe Atrial Functional TR (A) Case 1. Echocardiographic and invasive hemodynamic assessment of a patient with severe atrial functional TR. Assessment of TR jet velocity revealed a velocity of 2 m/s, suggesting that the RV-to-RA peak systolic pressure difference is 16 mm Hg by the modified Bernoulli equation, which in, fact was a pressure of 30 mm Hg. (B) Case 1. End-diastolic pulmonary regurgitation velocity was 1.7 m/s, suggesting that end-diastolic pulmonary pressure is 12 mm Hg + right atrial pressure. (C) Pulmonary acceleration time was 49 ms, and calculated mean pulmonary pressure (mean pulmonary pressure = 48 – [0.28 × pulmonary acceleration time]) was 34 mm Hg. (D) Invasive assessment performed on the day of echocardiographic assessment showing severely elevated mean and peak (V-wave) RA pressure (24 mm Hg and 33 mm Hg, respectively); significant peak, end-diastolic, and mean pulmonary hypertension (63 mm Hg, 22 mm Hg, and 37 mm Hg, respectively); and much higher RV-RA peak pressure difference (30 mm Hg) compared with the one calculated based on the TR jet. Importantly, systolic and diastolic calculated pressure values are supposed to be averaged values…

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  Figure 3. Case 2: TTE Images Demonstrate a Flail Septal Leaflet With Eccentric TR (A) RV inflow view. (B, C) Short-axis view. (D) Apical 4-chamber view. (E) Pulse Doppler of hepatic veins. TTE = transthoracic echocardiography; other abbreviations as in Figure 2.

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  Figure 4. Case 2: TEE Images Demonstrate a Flail Septal Leaflet With Severe TR (A) Long-axis view. (B) The x-plane of the RV inflow/short-axis view. (C) Flail segment captured by the MitraClip (Abbott) to tricuspid valve. (D) Two clips deployed with minimal residual regurgitation between the clips. TEE = transesophageal echocardiography; other abbreviations as in Figure 2.

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  Figure 5. Case 3 (A) Quantitative Doppler by the PISA method was technically difficult but consistent with severe TR. Aliasing velocity was 31 cm/s, proximal isovelocity surface area radius was 0.85 cm, TR velocity was 338 cm/s, and TR time velocity integral was 120 cm. Calculated ERO was 0.42 cm2 and regurgitant volume was 50 mL without or ERO was 0.5 cm2 and regurgitant volume was 60 mL with leaflet angle correction. (B) Doppler of hepatic veins showed systolic flow reversals, suggesting hemodynamically significant TR. (C) A transesophageal echocardiogram. TR jet vena contracta is 6 to 7 cm. Abbreviations as in Figure 1.

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  Figure 6. Case 4: Representation of Color Doppler Jets in Different 2-Dimensional TTE Sections When the probe is tilted to open the anterior part of the TV, with anteroseptal commissure, the jet is more flattened, suggesting a complex orifice and a possible underestimation of the jet. (A) Parasternal long-axis RV view. (B) Apical 4-chamber view. (C) Modified apical 4-chamber view. (D) The ERO area in functional TR is frequently lower than in primary TR and underestimated because of the low-flow state, the tethering, and the elliptical- or crescent-shaped or star-shaped orifice. Accounting for geometric distortion may help to reduce underestimation. Uncorrected ERO area was 0.30 cm2; the corrected ERO area by leaflet tethering angle (α = 223°) was 0.39 cm2, thus demonstrating a 30% underestimation of ERO area without angle correction; this was calculated as 6.28r2 × (aliasing velocity) × (α/180)/(TR peak velocity), where α was measured using a protractor generated by dedicated software. (E) Multiparametric 3D echocardiography. In the multiparametric approach, besides quantification of the 3D vena contracta area, the visualization of the shape of the 3D orifice with color Doppler may allow…