Measurement of the tricuspid annulus

Parameter for repair

Tricuspid regurgitation is far from being a benign pathology and, when moderate to important, has a negative impact on survival. In the same way as other heart valve diseases, it can also be classified as primary and secondary, being the management of the secondary more complex.

The joint approach of a functional tricuspid regurgitation with another valve disease is well established in the literature, even with a clear indication in the guidelines. One of the parameters used to define this approach is the diameter of the tricuspid annulus, measured in the 4-chamber apical window. Values above 40mm or 21mm/m2 indicate that the tricuspid valve is plastied, regardless of the degree of regurgitation.

Would we be facing a reliable measure?

To understand this, we need to start from some points that the three-dimensional comparison brought us. In patients with high degrees of regurgitation, the overall morphology of the ring is altered. We found a more rounded tricuspid ring and moved to posterior in cases with regurgitation greater than or equal to moderate.

In patients with long-standing permanent atrial fibrillation, we found an annular dilation in the posterior region of the tricuspid annulus, a region without direct contact with other cardiac structures.

Although there is a good correlation between two-dimensional transthoracic and three-dimensional transesophageal echocardiography measurements, absolute measurements are underestimated in the transthoracic measurement. The reason for this is that the spatial orientation of the annulus distribution is important for this measure.

Some studies suggest that in case we have a high degree of tricuspid regurgitation, we should change the measurement angle a little to try to correct this displacement of the annulus. Ideally, in order to achieve the largest diameter, the apical 4-chamber window should be searched for the RV entrance area with the coronary sinus, close to a coronal section of the ventricle.

However, in a practical way, considering traditional surgical correction, the three-dimensional evaluation was not superior, neither to indicate annuloplasty nor to predict results after the intervention. The great benefit of this more detailed assessment of the anatomy of the tricuspid valve came from percutaneous intervention. Understanding the most precise location of the regurgitation jet convergence zone and looking for the correlation between the leaflets and the orientation of the ring seems to be of extreme importance in the proper implantation of the device, such as mitraclip.

However, in a practical way, considering traditional surgical correction, the three-dimensional evaluation was not superior, neither to indicate annuloplasty nor to predict results after the intervention. The great benefit of this more detailed assessment of the anatomy of the tricuspid valve came from percutaneous intervention. Understanding the most precise location of the regurgitation jet convergence zone and looking for the correlation between the leaflets and the orientation of the ring seems to be of extreme importance in the proper implantation of the device, such as mitraclip.

With the improvement of techniques for percutaneous correction of tricuspid valve disease, we can use the three-dimensional evaluation by echocardiography, as well as other methods such as tomography and perhaps magnetic resonance imaging.

For now, for conventional surgical procedures, we continue to be guided by two-dimensional transthoracic echocardiography that has brought good results, but we must already prepare for a new phase of approaching the tricuspid valve.

Suggested literature:

1 – Utsunomiya H, Itabashi Y, Kobayashi S, Rader F, Siegel RJ, Shiota T. Clinical Impact of Size, Shape, and Orientation of the Tricuspid Annulus in Tricuspid Regurgitation as Assessed by Three-Dimensional Echocardiography. J Am Soc Echocardiogr. 2020; 33 (2): 191‐200.e1.

 

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