Elsevier

Progress in Cardiovascular Diseases

Volume 62, Issue 6, November–December 2019, Pages 459-462
Progress in Cardiovascular Diseases

Essential roles for CT and MRI in timing of therapy in tricuspid regurgitation

https://doi.org/10.1016/j.pcad.2019.11.018Get rights and content

Abstract

The rapid development of transcatheter tricuspid valve intervention (TTVI) therapies has quickly provided the opportunity to improve patient selection and procedural planning for patients with significant tricuspid regurgitation (TR) considered at high surgical risk.

This review focuses on the contributions which both computed tomography angiography and cardiac magnetic resonance can provide in the better understanding of the natural history of TR, in the comprehensive anatomical and functional assessment of right heart involvement and in the timing and planning for TTVI. We also discuss areas of potential importance such as the quantification of response to TTVI, which will be informative for future trials.

Introduction

Severity of tricuspid regurgitation (TR), right ventricle (RV) remodeling and RV function all have a direct impact on long-term survival, especially in patients with chronic heart failure and left ventricular (LV) dysfunction.1,2 The current guidelines for valvular heart disease lack class I indication for intervention in isolated severe TR, recommending only concomitant surgical tricuspid valve (TV) repair or replacement as class I indication in patients undergoing left-sided valve surgery with severe functional TR or with mild or moderate TR and severe dilation of the tricuspid annulus (TA).3 While transcatheter TV interventions (TTVI) have emerged as an alternative therapeutic option to serve a high risk population of patients with severe symptomatic TR, most of these patients already present late with advanced comorbidities.

This review describes the role for CTA and CMR in understanding of the natural history of TR, improvement in the anatomical and functional assessment of right heart involvement and TTVI planning.

Section snippets

Anatomical changes and challenges in right heart involvement

Transthoracic echocardiography (TTE) is the first imaging modality for TR evaluation, but known to have important limitations on the accurate and reproducible assessment of TR severity, TV anatomy, and RV remodeling and function. Although societal guidelines promote the use of quantitative Doppler to assess TR severity,4 in the majority of times qualitative, color Doppler jet area is actually the method used which leads to a consistent underestimation and under calling of the true TR severity.

Role of CTA for functional assessment of right-side and TTVI

Multiphasic, contrast-enhanced, retrospective cardiac-gated acquisition, encompassing the entire heart silhouette and proximal main vessels enables subsequent multiplanar reconstruction and comprehensive evaluation of the right heart.

Specific CT acquisition protocols focusing on the right-side should be followed to maximize image quality for analysis. New generation of CT scanners, with higher number of detectors enables shorter breath-hold, lower radiation and contrast utilization. Since

Emerging role for cardiac magnetic resonance in TR and TTVI

CMR has the advantage of assessing cardiac anatomy and function with excellent spatial resolution and without body habits limitations, ionizing radiation and need for contrast injection. Dedicated RV views from multiple planes allow for comprehensive assessment of the RV size and function.7,8

CMR can provide quantification of TR volume and TR fraction by both direct (using RV-LV stroke volume) and indirect methods (using phase-contrast imaging). However, CMR quantification of TR severity has

Conclusions

Multimodality cross-sectional imaging with CTA and CMR have an emerging and complementary use to echocardiography. They are key in the comprehensive evaluation of the right-sided unit. In the context of TTVI, their importance will continue to grow and inform us on the ideal timing, patient selection, procedural planning and response to therapies tackling TR.

Funding

None.

Statement of conflict of interest

Drs Sorajja and Cavalcante received consulting fees and research grants from Abbott Vascular. Dr. Cavalcante received research support from Circle Cardiovascular Imaging. None of the other authors have any relevant disclosure related to the content of this manuscript.

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