Skip to main content
SpringerLink
Log in

Three-dimensional echocardiography investigation of the mechanisms of tricuspid annular dilatation

  • Original Paper
  • Published:
The International Journal of Cardiovascular Imaging Aims and scope Submit manuscript

Abstract

Tricuspid annular (TA) size, assessed by 2D transthoracic echocardiography (TTE), has a well-established prognostic value in patients undergoing mitral valve surgery, with TA dilatation triggering simultaneous tricuspid annuloplasty. While TA dilatation is common in patients with dilated atria secondary to atrial fibrillation, little is known about the mechanisms of TA dilatation in patients with sinus rhythm (SR). This study aimed to identify echocardiographic parameters most closely related to the TA size as a potential tool for identification of patients prone to developing TA enlargement. 120 patients with SR underwent clinically indicated TTE, including 30 patients with normal hearts and 90 patients diagnosed with at least one right heart abnormality, defined as: right ventricular (RV) or right atrial (RA) dilatation, ≥ moderate tricuspid regurgitation (TR) and elevated systolic pulmonary artery pressure (sPAP). RA and RV end-diastolic and end-systolic volumes (EDV, ESV) and function were measured using commercial 3D software (TomTec). 3D RV long and short axes were used as surrogate indices of RV shape. Degrees of TR and sPAP were estimated by 2D TTE. 3D TA sizing was performed at end-diastole using 3D custom software. Linear regression analysis was used to identify variables best correlated with TA size, followed by multivariate analysis to identify independent associations. The highest correlations were found between TA area and: RA ESV (r = 0.73; p < 0.01), RV EDV (r = 0.58; p < 0.01), RV end-diastolic long and short axes (r = 0.53, 0.42; both p < 0.01), TR degree (r = 0.40; p < 0.01) and sPAP (r = 0.32; p < 0.01). Multivariate analysis revealed that RA ESV was the only parameter independently associated with TA area (p < 0.05, r = 0.85). In conclusion, RA volume plays an important role in TA dilatation even in patients with normal SR. Understanding of annular remodeling mechanisms could aid in identifying patients at higher risk for TA dilatation, especially those scheduled for mitral valve surgery.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4

Similar content being viewed by others

Abbreviations

EF:

Ejection fraction

FAC:

Fractional area change

MR:

Mitral regurgitation

MV:

Mitral valve

PISA:

Proximal isovelocity surface area

SR:

Sinus rhythm

sPAP:

Systolic pulmonary artery pressure

3D:

Three-dimensional

TA:

Tricuspid annular

TAPSE:

Tricuspid annular plane systolic excursion

TR:

Tricuspid regurgitation

TV:

Tricuspid valve

2D:

Two-dimensional

RV:

Right ventricular

VC:

Vena contracta

References

  1. Baumgartner H, Falk V, Bax JJ et al (2017) 2017 ESC/EACTS guidelines for the management of valvular heart disease. Eur Heart J 38:2739–2791

    Article  Google Scholar 

  2. Nishimura RA, Otto CM, Bonow RO et al (2017) 2017 AHA/ACC focused update of the 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 70:252–289

    Article  Google Scholar 

  3. Asmarats L, Puri R, Latib A et al (2018) Transcatheter tricuspid valve interventions: landscape, challenges, and future directions. J Am Coll Cardiol 71:2935–2956

    Article  Google Scholar 

  4. Hausleiter J, Braun D, Orban M et al (2018) Patient selection, echocardiographic screening and treatment strategies for interventional tricuspid repair using the edge-to-edge repair technique. EuroIntervention 14:645–653

    Article  Google Scholar 

  5. Utsunomiya H, Itabashi Y, Mihara H et al (2017) Functional tricuspid regurgitation caused by chronic atrial Fibrillation: a real-time 3-dimensional transesophageal echocardiography study. Circ Cardiovasc Imaging 10:e004897

    Article  Google Scholar 

  6. Nath J, Foster E, Heidenreich PA (2004) Impact of tricuspid regurgitation on long-term survival. J Am Coll Cardiol 43:405–409

    Article  Google Scholar 

  7. Koelling TM, Aaronson KD, Cody RJ et al (2002) Prognostic significance of mitral regurgitation and tricuspid regurgitation in patients with left ventricular systolic dysfunction. Am Heart J 144:524–529

    Article  Google Scholar 

  8. Topilsky Y, Nkomo VT, Vatury O et al (2014) Clinical outcome of isolated tricuspid regurgitation. JACC Cardiovasc Imaging 7:1185–1194

    Article  Google Scholar 

  9. Benedetto U, Melina G, Angeloni E et al (2012) Prophylactic tricuspid annuloplasty in patients with dilated tricuspid annulus undergoing mitral valve surgery. J Thorac Cardiovasc Surg 143:632–638

    Article  Google Scholar 

  10. Dreyfus GD, Corbi PJ, Chan KM et al (2005) Secondary tricuspid regurgitation or dilatation: which should be the criteria for surgical repair? Ann Thorac Surg 79:127–132

    Article  Google Scholar 

  11. Van de Veire NR, Braun J, Delgado V et al (2011) Tricuspid annuloplasty prevents right ventricular dilatation and progression of tricuspid regurgitation in patients with tricuspid annular dilatation undergoing mitral valve repair. J Thorac Cardiovasc Surg 141:1431–1439

    Article  Google Scholar 

  12. Shiran A, Sagie A (2009) Tricuspid regurgitation in mitral valve disease incidence, prognostic implications, mechanism, and management. J Am Coll Cardiol 53:401–408

    Article  Google Scholar 

  13. Chikwe J, Itagaki S, Anyanwu A et al (2015) Impact of concomitant tricuspid annuloplasty on tricuspid regurgitation, right ventricular function, and pulmonary artery hypertension after repair of mitral valve prolapse. J Am Coll Cardiol 65:1931–1938

    Article  Google Scholar 

  14. Pettinari M, De Kerchove L, Lazam S et al (2018) Mid-term results of a randomized trial of tricuspid annuloplasty for less-than-severe functional tricuspid regurgitation at the time of mitral valve surgery†. Eur J Cardiothorac Surg 55(5):851–858

    Article  Google Scholar 

  15. Seeburger J, Borger MA, Falk V et al (2008) Minimal invasive mitral valve repair for mitral regurgitation: results of 1339 consecutive patients. Eur J Cardiothorac Surg 34:760–765

    Article  Google Scholar 

  16. Fukuda S, Saracino G, Matsumura Y et al (2006) Three-dimensional geometry of the tricuspid annulus in healthy subjects and in patients with functional tricuspid regurgitation: a real-time, 3-dimensional echocardiographic study. Circulation 114:I492–I498

    PubMed  Google Scholar 

  17. Duran CM, Pomar JL, Colman T et al (1980) Is tricuspid valve repair necessary? J Thorac Cardiovasc Surg 80:849–860

    Article  CAS  Google Scholar 

  18. Kara I, Koksal C, Erkin A et al (2015) Outcomes of mild to moderate functional tricuspid regurgitation in patients undergoing mitral valve operations: a meta-analysis of 2488 patients. Ann Thorac Surg 100:2398–2407

    Article  Google Scholar 

  19. Miglioranza MH, Mihăilă S, Muraru D et al (2015) Variability of tricuspid annulus diameter measurement in healthy volunteers. JACC Cardiovasc Imaging 8:864–866

    Article  Google Scholar 

  20. Miglioranza MH, Mihăilă S, Muraru D et al (2015) Dynamic changes in tricuspid annular diameter measurement in relation to the echocardiographic view and timing during the cardiac cycle. J Am Soc Echocardiogr 28:226–235

    Article  Google Scholar 

  21. Volpato V, Lang RM, Yamat M et al (2019) Echocardiographic assessment of the tricuspid annulus: the effects of the third dimension and measurement methodology. J Am Soc Echocardiogr 32(2):238–247

    Article  Google Scholar 

  22. Lang RM, Badano LP, Mor-Avi V et al (2015) Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr 28(1–39):e14

    Google Scholar 

  23. Tamborini G, Fusini L, Muratori M et al (2016) Right heart chamber geometry and tricuspid annulus morphology in patients undergoing mitral valve repair with and without tricuspid valve annuloplasty. Int J Cardiovasc Imaging 32:885–894

    Article  Google Scholar 

  24. Addetia K, Muraru D, Veronesi F, et al. (2019) 3-Dimensional echocardiographic analysis of the tricuspid annulus provides new insights into tricuspid valve geometry and dynamics. J Am Coll Cardiol Cardiovasc Img 12:401–412. https://doi.org/10.1016/j.jcmg.2017.08.022

    PubMed  Google Scholar 

  25. Nemoto N, Schwartz JG, Lesser JR et al (2017) The right atrium and tricuspid annulus are cardinal structures in tricuspid regurgitation with or without pulmonary hypertension. Int J Cardiol 230:171–174

    Article  Google Scholar 

  26. Nemoto N, Lesser JR, Pedersen WR et al (2015) Pathogenic structural heart changes in early tricuspid regurgitation. J Thorac Cardiovasc Surg 150:323–330

    Article  Google Scholar 

  27. Buzzatti N, De Bonis M, Moat N (2018) Anatomy of the tricuspid valve, pathophysiology of functional tricuspid regurgitation, and implications for percutaneous therapies. Interv Cardiol Clin 7:1–11

    PubMed  Google Scholar 

  28. Medvedofsky D, Aronson D, Gomberg-Maitland M et al (2017) Tricuspid regurgitation progression and regression in pulmonary arterial hypertension: implications for right ventricular and tricuspid valve apparatus geometry and patients outcome. Eur Heart J Cardiovasc Imaging 18:86–94

    Article  Google Scholar 

  29. Izumi C, Miyake M, Takahashi S et al (2011) Progression of isolated tricuspid regurgitation late after left-sided valve surgery. Clinical features and mechanisms. Circ J 75:2902–2907

    Article  Google Scholar 

  30. Navia JL, Nowicki ER, Blackstone EH et al (2010) Surgical management of secondary tricuspid valve regurgitation: annulus, commissure, or leaflet procedure? J Thorac Cardiovasc Surg 139(1473–82):e5

    Google Scholar 

  31. McCarthy PM, Bhudia SK, Rajeswaran J et al (2004) Tricuspid valve repair: durability and risk factors for failure. J Thorac Cardiovasc Surg 127:674–685

    Article  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Section of Cardiology, Cardiac Imaging Center, University of Chicago Medical Center, 5758 S. Maryland Ave., MC 9067, Chicago, IL, 60637, USA

    Valentina Volpato, Victor Mor-Avi, Karima Addetia, Megan Yamat, Lynn Weinert, Davide Genovese & Roberto M. Lang

  2. Department of Cardiovascular Imaging, Centro Cardiologico Monzino IRCCS, Milan, Italy

    Valentina Volpato, Gloria Tamborini & Mauro Pepi

  3. Department of Electrical, Electronics and Information Engineering, University of Bologna, Bologna, Italy

    Federico Veronesi

Authors
  1. Valentina Volpato
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Victor Mor-Avi
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Federico Veronesi
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Karima Addetia
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Megan Yamat
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Lynn Weinert
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Davide Genovese
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Gloria Tamborini
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Mauro Pepi
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Roberto M. Lang
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Roberto M. Lang.

Ethics declarations

Conflict of interest

The authors declare that they have no competing interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

The study was approved by the Institutional Review Board with a waiver of consent.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Volpato, V., Mor-Avi, V., Veronesi, F. et al. Three-dimensional echocardiography investigation of the mechanisms of tricuspid annular dilatation. Int J Cardiovasc Imaging 36, 33–43 (2020). https://doi.org/10.1007/s10554-019-01686-7

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10554-019-01686-7

Keywords

Search

Navigation