Elsevier

American Heart Journal

Volume 152, Issue 6, December 2006, Pages 1208-1214
American Heart Journal

Clinical Investigation
Valvular and Congenital Heart Disease
Echocardiographic insights into atrial and ventricular mechanisms of functional tricuspid regurgitation

https://doi.org/10.1016/j.ahj.2006.07.027Get rights and content

Background

The etiology of functional tricuspid regurgitation (TR) is thought to be annular dilatation and tethering of tricuspid valve (TV) leaflets. However, mechanisms of leaflet tethering are incompletely understood. The purpose of this study was therefore to investigate the relationships between TV annular dilatation and leaflet tethering with the severity of functional TR and to investigate factors that influence these TV deformations.

Methods

Two hundred forty-five patients with functional TR had 2-dimensional echocardiography. Echocardiographic investigations focused on the ventricles and on the TV. Ventricular measurements included left ventricular (LV) volume, right ventricular (RV) area, and RV spherical index. Valvular measurements included systolic TV annular dimension and apical displacement (tethering height), as well as severity of TR (vena contracta width).

Results

Tethering height (r2 = 0.25) was related to the severity of TR (P < .001). The RV and right atrium areas influenced both annular dimension and tethering height. However, LV ejection fraction and RV spherical index affected tethering height but not annular dimension.

Conclusions

Tethering of TV leaflets, a determinant of functional TR, is associated with changes in right-sided cavity size as well as RV sphericity and LV function, emphasizing the impact of changes in ventricular geometry and function on the severity of functional TR.

Section snippets

Patients

A total of 384 consecutive patients with functional TR who had transthoracic 2-dimensional echocardiography initially enrolled from the Cleveland Clinic Foundation echocardiography database, which was approved by the Institutional Review Board for clinical research. Functional TR was defined as (1) >2+ TR on the clinical echocardiographic report based on a scale of 0 to 4+, (2) without any organic TV diseases, and (3) no history of prior TV surgery. Patients with congenital heart disease (n =

Characteristics

Echocardiographic results in patients with TR and in controls were summarized in Table I.

Relationship between TR severity and echocardiographic parameters

In the univariate analysis, TR severity (VCW) was correlated with RV systolic area, RV long-axis dimension, RV spherical index, RA area, TV annular dimension, and tethering height as shown in Table II. When these 6 parameters were entered into the stepwise multivariate regression analysis, RV spherical index (P = .03), RA area (P < .001), and tethering height (P < .001) were significant factors.

In

Key findings

This study emphasizes the importance of leaflet tethering on the pathogenesis of functional TR. Tethering of the TV leaflets is sufficient to cause TR even in the absence of significant TV annular dilatation. Tethering of TV leaflets is associated with changes in right-sided cavity size, RV sphericity, and LV function, demonstrating the impact of changes in ventricular geometry and function on the pathogenesis of functional TR.

Impact of tethering of TV leaflets on the severity of functional TR

Previous echocardiographic and angiographic studies reported that RV

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Disclosures: Dr Gillinov has served as consultant to Edwards Lifesciences, LLC.

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