Clinical Investigation
Echocardiography in Children
Tricuspid Regurgitation in Hypoplastic Left Heart Syndrome: Three-Dimensional Echocardiography Provides Additional Information in Describing Jet Location

https://doi.org/10.1016/j.echo.2020.12.010Get rights and content

Highlights

  • 2DE has poor reproducibility and agreement with 3DE for TR location.

  • 3DE is highly reproducible in determining TR location in HLHS.

  • HLHS TR is located centrally pre-Glenn and centrally and AS post-Glenn.

Background

Twenty-five percent of patients with hypoplastic left heart syndrome (HLHS) require tricuspid valve (TV) repair. The location of tricuspid regurgitation (TR) is important in determining the type of repair performed. Studies using three-dimensional echocardiography (3DE) have reported a high incidence of error on two-dimensional echocardiography (2DE) for the identification of TV leaflets. The aim of this study was to compare assessment of TR on 3DE and 2DE in patients with HLHS (jet location, TR grade, and reproducibility).

Methods

A retrospective, single-center review was performed. Fifty-six patients with HLHS with available two-dimensional and three-dimensional echocardiograms, and mild or greater TR, were included. TR location, grade, vena contracta area, and TV annular diameter were measured on 2DE and 3DE. Reproducibility was assessed by blinded reviewers.

Results

Three-dimensional echocardiography identified the primary jet location as central (57%) followed by anteroseptal (36%). There was poor agreement between findings on 3DE and 2DE for jet location (κ = 0.05; 95 CI, −0.08 to 0.19). Interobserver reproducibility for location on 3DE was excellent (κ = 0.8), whereas reproducibility for 2DE was poor (κ = 0.32). The most common jet location pre-Norwood and pre-Glenn was central (70%), whereas pre-Fontan and post-Fontan, jet location was central (45%) and anteroseptal (48%). Vena contracta area on 2DE correlated moderately with vena contracta area on 3DE (r = 0.60, P < .0001). TV annular diameters on 2DE and 3DE for lateral (r = 0.85, P < .0001) and anteroposterior (r = 0.74, P = .001) dimensions were strongly correlated.

Conclusions

In children with HLHS, assessment of TR location on 2DE had poor agreement with assessment on 3DE and was poorly reproducible. In contrast, TR jet location on 3DE was highly reproducible. Pre-Glenn, a central TR jet was the most common, while post-Glenn, central and anteroseptal locations were equal, highlighting the importance of preoperative identification of TR jet location in patients with HLHS.

Section snippets

Methods

A retrospective study was performed among all patients with HLHS managed at a quaternary-level pediatric cardiac surgical center in Canada between January 1, 2005, and June 30, 2016. The interprovincial centralized database, 3DE and 2DE databases, hospital records, and clinical charts were reviewed. Subjects meeting the inclusion criteria were patients with HLHS who had mild or greater TR and had undergone 2DE and 3DE within 2 weeks of each other. Those patients who underwent TV surgery were

Results

From January 2005 to December 2016, 57 patients with HLHS met the inclusion criteria. Of the 57 patients, one had inadequate 3D echocardiographic images for analysis and was excluded from the study (feasibility of 3DE 98%). All patients had adequate 2D echocardiographic images for interpretation (feasibility of 2DE 100%). Fifty-four patients had adequate transthoracic echocardiograms (2DE and 3DE), and two patients had transesophageal echocardiograms (2DE and 3DE) for analysis in the study.

Discussion

The main findings of this study in patients with HLHS are that assessment of TR location on 2DE has poor agreement with TR location on 3DE. In addition, assessment of TR jet location on 2DE was poorly reproducible, which challenges the usefulness of 2DE for surgical planning beyond simple assessment of TV annular size and qualitative TR severity. In contrast, TR jet location on 3DE was highly reproducible.

Conclusion

In children with HLHS, assessment of TR location on 2DE has poor agreement with TR location on 3DE and was poorly reproducible. In contrast, TR jet location on 3DE was highly reproducible and is likely to provide reliable preoperative information on jet location for surgical planning. A single, central TR jet was the most common in patients with HLHS pre-Glenn, while post-Glenn TR occurred equally in the center (where all the leaflets meet) and at the AS closure line, highlighting the potential

References (29)

Cited by (7)

  • Hypoplastic Left Heart Syndrome Across the Lifespan: Clinical Considerations for Care of the Fetus, Child, and Adult

    2022, Canadian Journal of Cardiology
    Citation Excerpt :

    Insights from these technologies have also enabled design of more “futuristic” models of a Fontan circulation, including the possible incorporation of a pulsatile subpulmonary “neoventricle” from engineered heart tissue, thus providing additional energy to drive pulmonary blood flow as well as other devices designed to propel blood through the Fontan circuit.131,132 As tricuspid valve regurgitation is another important determinant of long-term outcomes, research directed toward a deeper understanding of the mechanisms of progressive tricuspid valve dysfunction in HLHS could result in optimisation of surgical techniques and strategies for repair.133-136 As neurologic outcomes remain uncertain, further study into factors that contribute to poor neurologic outcomes are required before development of preventive strategies can occur.

View all citing articles on Scopus

This study was generously sponsored by the Stollery Children's Hospital Foundation through the Women and Children's Health Research Institute.

Conflicts of interest: None.

View full text