Clinical Investigation
Echocardiography in Valvular Heart Diseases
Geometry of Tricuspid Valve Apparatus in Patients with Mitral Regurgitation due to Fibroelastic Deficiency versus Barlow Disease: A Real-Time Three-dimensional Transesophageal Echocardiography Study

https://doi.org/10.1016/j.echo.2020.04.019Get rights and content

Highlights

  • •

    TV geometry of BD patients differed from that in FED patients, similar to MV.

  • •

    The prevalence of significant residual TR after TAP was greater in BD than in FED.

  • •

    TV geometry before TAP was associated with the severity of residual TR after TAP.

Background

Tricuspid valve (TV) geometry gained attention when the prognostic significance of tricuspid regurgitation (TR) was determined. However, the TV geometric characteristics in Barlow disease (BD) have not been elucidated. This study aimed to clarify the difference in TV morphology between BD and fibroelastic deficiency (FED) and the effect of its geometry on residual TR after tricuspid annuloplasty (TAP) using three-dimensional (3D) transesophageal echocardiography.

Methods

Based on the mitral valve (MV) morphology defined by 3D transesophageal echocardiography, 106 patients with degenerative MV disease were classified into BD (n = 42) and FED (n = 64). Three-dimensional images of the TV were analyzed using a quantification software to compare the geometrical parameters. Among them, 35 patients (17 with BD and 18 with FED) underwent concomitant TAP during MV surgery, and the residual TR after TAP was evaluated within 1 month.

Results

TV annulus area, billowing height, and billowing volume were greater in BD than in FED (10.8 ± 2.9 vs 9.2 ± 2.4 cm2, 4.6 ± 1.6 vs 2.3 ± 1.1 mm, and 1.3 ± 0.8 vs 0.3 ± 0.3 mL; all P < .01). In contrast, TV tenting height and tenting volume were smaller in BD than in FED (2.6 ± 1.5 vs 4.4 ± 2.4 mm and 0.3 ± 0.4 vs 0.9 ± 1.0 mL; both P < .01). These morphologic differences in TV were similar to those in MV. There was a strong correlation between MV billowing volume and TV billowing volumes (R = 0.83, P < .01). The prevalence of significant residual TR after TAP was greater in BD than in FED (35% vs 0%, P < .01). Moderate correlations between TV billowing height and volume and residual TR after TAP were observed (R = 0.47 and 0.49, respectively, both P < .01).

Conclusions

Patients with BD exhibited larger TV annulus area and billowing than FED patients. These results suggest that degenerative changes in the TV apparatus in BD patients are similar to that seen in the MV apparatus. These findings should be taken into consideration when a TV surgery is required.

Section snippets

Study Population

This study included 148 patients with moderate and severe MR due to DMVD who underwent 3D TEE for MV and TV assessments between January 2013 and February 2017 in two institutions (St. Marianna University Hospital, 123 cases; Tokyo Medical and Dental University Hospital, 25 cases). Patients diagnosed with Marfan syndrome and those with any connective tissue diseases were excluded as well as those with insufficient TEE image quality (n = 21), aortic valve disease (n = 9), infective endocarditis (n

Baseline Characteristics

Table 1 shows the baseline characteristics. All patients were stratified into two groups according to MV prolapse volume: BD (n = 42) and FED (n = 64) groups (Figure 1). Although no significant differences in age, sex, or body surface area were observed between the two groups, the BD group showed significantly lower weight and body mass index (BMI; P = .02 and P < .001, respectively) than the FED group. In addition, the BD group showed a significantly lower BMI compared with the controls.

Discussions

Recently, 3D echocardiography and dedicated software has enabled a detailed assessment of the geometrical characteristics of cardiac valves, including the TV.14,15 The main findings of this study were as follows: (1) Similar to MV geometry, TV geometry in patients with BD differed from that in patients with FED; nevertheless, no differences in LV or RV chamber size were observed between the BD and FED groups. (2) The prevalence of significant residual TR shortly after TAP was greater in the BD

Conclusion

Using 3D TEE, we clarified the differences in TV geometrical characteristics between BD and FED. Similar to the MV, the TV in BD was characterized by annular dilatation and leaflet billowing. These results suggested that the degenerative changes of TV could occur in a way similar to the MV in BD patients. These geometrical differences should be taken into consideration when TV surgery is required.

Acknowledgment

The authors would like to thank Victoria Delgado, Leiden University Medical Center, for helpful advice on the manuscript.

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    Conflicts of Interest: None.

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    2020 by the American Society of Echocardiography.