Author + information
- Marcelo Haertel Miglioranza, MD, PhD,
- Sorina Mihăilă, MD, PhD,
- Denisa Muraru, MD, PhD,
- Umberto Cucchini, MD, PhD,
- Sabino Iliceto, MD and
- Luigi P. Badano, MD, PhD∗ ()
- ↵∗Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Via Giustiniani 2, 35128 Padua, Italy
Tricuspid valve (TV) anatomy and function play an important prognostic role in several heart diseases and in the development of functional tricuspid regurgitation. According to current guidelines for management of heart valve disease, the tricuspid annulus (TA) diameter measured by 2-dimensional transthoracic echocardiography (2DE) should be used to define the need of an associated TA annuloplasty in patients undergoing cardiac surgery for left-sided heart valve diseases (1,2). However, the timing during the cardiac cycle when the TA should be measured remains to be established. Moreover, normative data about TA diameter and function are limited (3–5).
Therefore, we designed a prospective cross-sectional study of 219 normal volunteers (age 43 ± 15 years; 57% female; body mass index <30 kg/m2) to assess the variability of TA diameter measurement in 2DE 4-chamber view (4CH) in relation to timing during the cardiac cycle.
The TA diameter was obtained from the apical right ventricular (RV)–focused 4CH using a Vivid E9 (GE Vingmed, Horten, Norway) equipped with M5S probe and measured as the distance between the insertion points of the TV leaflets (inner edge to inner edge) at 5 time points during the cardiac cycle. The times during the cardiac cycle were determined using both electrocardiogram and valve dynamic visualization: TV closure (end-diastole—the first frame after the TV closure), mid-systole (beginning of T-wave), end-systole (end of T-wave), TV opening early filling (as the frame with the TV wide open during passive flow), TV opening late filling (as the frame with the TV wide open during active flow—after P-wave). Fractional shortening (FS) of the TA diameter was calculated using the largest and smallest diameters and expressed as a percentage. Right atrial (RA) and RV volumes were obtained using 3DE full-volume datasets acquired with a 4V matrix-array transducer (GE Vingmed) and measured using dedicated software designed for volumetric analysis of the left atrium (LA and RV analysis, Tomtec Imaging Systems, Unterschleissheim, Germany).
The feasibility of measuring the TA diameter in 4CH by 2DE was 99.5%. Absolute TA diameters were significantly larger in men than in women. However, this difference was eliminated after indexation by body surface area (Figure 1). In healthy subjects, the TA diameter increased from mid-systole to early diastole and then decreased (FS 24.1 ± 6.2%; Δ 8.0 ± 2.4 mm; p < 0.001), with a consistent correlation with the phasic changes of RA (r = 0.56; p < 0.001) and RV volumes (r = 0.53; p < 0.001), and height (r = 0.49; p < 0.001), weight (r = 0.54; p < 0.001). At multivariate linear regression analysis, age (r2 = 0.2; p < 0.001), sex (r2 = 0.2; p = 0.002), and RA (r2 = 0.45; p < 0.001) and RV volumes (r2 = 0.2; p < 0.001) were independently correlated with TA absolute diameters and accounted for 55% of the variance of mid-systolic TA diameter in the 4CH view.
Applying the cutoff values for TA annuloplasty proposed in the current guidelines and in published reports (TA >40 mm or FS <25%) (1,2,4) to our study population resulted in a significant number of our healthy subjects fulfilling 1 or more criteria for intervention: 19.7% with dilated early diastolic TA in 4CH view (95% confidence interval: 14.4 to 25) and 58% with reduced FS in the 4CH view (95% confidence interval: 51.2 to 64.4).
It is well known that the complex geometry of the TA is difficult to assess by a tomographic imaging technique like 2DE. However, current guidelines recommend 2DE to assess TA size and indicate the need for tricuspid annuloplasty. The present study provided reference values for TA diameter obtained in the 4CH view specific for 2DE and identified the main determinants of TA size. Age, sex, and right chamber sizes, as well as the timing during the cardiac cycle, significantly influence the TA diameter in 4CH in healthy individuals. According to our data, TA evaluation to define the need for TV annuloplasty should include diameter measurements at both mid-systole and early diastole, complemented with right heart chamber volumes. Our data may help to correctly identify TA enlargement by 2DE.
Please note: Dr. Miglioranza has received a post-graduate grant from CAPES, a Brazilian governmental agency for post-graduate support. Dr. Mihăilă has received a research grant from the European Association of Cardiovascular Imaging. Drs. Muraru and Badano have received equipment grants from and served on the speakers bureau for GE Healthcare. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
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