TEKNIK PEMERIKSAAN

TRANSTHORACIC
ECHOCARDIOGRAPHY (TTE) PADA
PENYAKIT KATUP JANTUNG
MUHAMMAD ASRUL APRIS
TRICUSPID REGURGITATION (MR)
DEFINITION

• Backflow of blood from right ventricle (RV) to right atrium (RA)

• Typically TR occurs during systole, but in rare conditions (i.e. AV block) it
may occur also during diastole
CLINICAL FEATURES

Symptons

Examinations
AETIOLOGY
Primary TR (organic, structural): evident structural abnormalities of TV leaflets
• Acquired : rheumatic disease, degenerative or Barlow disease, infective
endocarditis, carcinoid, traumatic, pacemaker-related, connective tissue
disease, radiotherapy
• Congenital : Ebstein anomaly, atrioventricular septal defect, etc.

Secondary TR (functional, non-structural)

• TV malcoaptation due to enlargement and/ or dysfunction of TV
annulus/RV/RA, with no significant structural abnormalities of TV leaflets
(i.e. pulmonary hypertension, RV dilation, RV dysfunction, atrial
fibrillation)
ROLE OF ECHO

Imaging of AS patients should evaluate the aetiology :

• Mechanism
• Dysfunction
• Severity of regurgitation
• Consequences
• Possibility of repair
TRICUSPID VALVE ANATOMY/IMAGING

• Normally, TV is located slightly more apical than mitral valve

• TV complex includes:
◆ three leaflets of unequal size (anterior usually the largest,
posterior, and septal) (Fig. 7.7.1)
◆ annulus
◆ subvalvular apparatus (chordae and papillary muscles)
◆ RV and RA
• TV annulus has an oval, non-planar structure with a saddle-shaped
pattern, having two high points (oriented superiorly towards the
RA) and two low points (oriented inferiorly toward the RV)
TRICUSPID VALVE IMAGING
 MECHANISM: LESION/DEFORMATION
RESULTING IN VALVE DYSFUNCTION
Mechanism of TR
• Prolapse/flail (Fig. 7.7.3AB), thickened leaflets with
Primary commissural fusion (Fig. 7.7.3CD), restricted mobility
TR (Fig. 7.7.3EF), vegetations (Fig. 7.7.3GH), interference
by catheters, etc.

• no structural abnormalities of leaflets

• annular dilation/planar annulus
• tethering of leaflets
• papillary muscle displacement
• ventricular deformation/remodelling
Secondar • echo-morphological parameters
y TR • RV remodelling: RV sizes, volumes, function
• Tricuspid valve (TV) deformation (Fig. 7.7.4)
• tenting area (TA)
• coaptation distance (CD)
 MECHANISM: LESION/DEFORMATION
RESULTING IN VALVE DYSFUNCTION
Mechanism of dysfunction (Carpentier's
classification)
Type I: Normal Leaflet Motion
• Annular dilatation (rarely isolated) (Fig. 7.7.5)
• Leaflet perforation (infective endocarditis)
Type II: excessive Leaflet Mobility
• Prolapse
• Flail leaflet (Fig. 7.7.3AB)
Type III: Reduced Leaflet Mobility or
Motion
• IIIa: systolic + diastolic restriction due to chordae
shortening, leaflet thickening (rheumatic disease,
toxic valvulopathy, radiation-induced TV disease)
(Fig. 7.7.6)
• IIIb: systolic restriction: secondary TR (Fig.
 ASSESSMENT OF TR SEVERITY
Tricuspid valve morphology

• Visual assessment
Technique
• Multiple views

Usefulness/ • Flail valve is specific for significant

Advantages TR (Fig. 7.7.7)

• Other abnormalities are non-specific

Limitations
of significant TR
 ASSESSMENT OF TR SEVERITY
Colour-flow imaging in TR

• Optimize colour gain/scale

Technique • Need blood pressure evaluation

Usefulness
• Ease of use
/
• Evaluates the spatial orientation of TR jet
Advantage • Good screening test for mild vs severe TR
s

• Can be inaccurate for estimation of TR severity

• Influenced by technical and haemodynamic factors (Fig.
Limitations 7.7.8)
• Underestimates eccentric jet adhering the RA wall
(Coanda effect) (Fig. 7.7.9)
 ASSESSMENT OF TR SEVERITY
Vena contracta width in TR
• Apical 4CV (Fig. 7.7.10ABC)
• Optimize colour gain/scale (40–70 cm/s Nyquist limit)
• Identify the three components of the regurgitant jet (VC, PISA, jet into RA)
• Reduce the colour sector size and imaging depth to maximize frame rate
Technique • Expand the selected zone (zoom)
• Use the cine loop to find the best frame for measurement
• Measure the smallest VC (immediately distal to the regurgitant orifice, perpendicular to the direction of the
jet)
• The VC is the area of the jet as it leaves the regurgitant orifice; it reflects thus the regurgitant orifice area

• Relatively quick and easy

• Relatively independent of haemodynamic and instrumentation factors
Usefulness/
• Not affected by other valve leak
Advantages • Good for extreme TR: mild vs severe
• Can be used in eccentric jet

• Not valid for multiple jets

• Small values; small measurement errors leads to large % error
Limitations • Intermediate values need confirmation
• Affected by systolic changes in regurgitant flow

Interpretation • Severe TR : VC > 7 mm

 ASSESSMENT OF TR SEVERITY
PISA method in TR: recordings
• Apical 4CV (Figs. 7.7.11 and 7.7.12ABCDEF)
• Optimize colour-flow imaging of TR
• Zoom the image of the regurgitant TV
• Decrease the Nyquist limit (colour-flow zero baseline)
Technique • With the cine mode select the best PISA
• Display the colour off and on to visualize the TR orifice
• Measure the PISA radius at mid-systole using the first aliasing and along the direction of the ultrasound beam
• Measure TR peak velocity and TVI (CW)
• Calculate flow rate, EROA, R Vol

• Can be used in eccentric jet (Fig. 7.7.13)

Usefulness/
• Not affected by the aetiology of TR or other valve leak
Advantages • Quantitative: estimate lesion severity (EROA) and volume overload (R Vol)

• PISA shape affected

• by the aliasing velocity
• in case of non-circular orifice (Fig. 7.7.14)
• by systolic changes in regurgitant flow
Limitations • by adjacent structures (flow constrainment)
• Errors in PISA radius measurement are squared
• Inter-observer variability
• Validated in only few studies

• A TR PISA radius > 9 mm at a Nyquist limit of 28 cm/s indicates severe TR

Interpretation • Severe TR EROA ≥ 40 mm2
ASSESSMENT OF TR SEVERITY
3D vena contracta (VC)—PISA in TR
• VC area calculation assumes a circular or elliptical orifice

• Complex geometry and various shapes of the VC (Fig. 7.7.15)

• 3D VC data are limited

• An EROA > 75 mm2 seems to indicate severe TR

 ASSESSMENT OF TR SEVERITY
Hepatic vein flow

• Subcostal view (Fig. 7.7.16)

Technique • Sample volume of PW places into the
hepatic vein (Fig. 7.7.17)

Usefulness/
• Simple
Advantages

• Affected by RA pressure
Limitations
• Affected by atrial fibrillation

• Systolic flow reversal is specific for severe

Interpretation
TR
 ASSESSMENT OF TR SEVERITY
Peak E velocity

• Apical 4CV
Technique • Sample volume of PW places at tricuspid
leaflet tips (Fig. 7.7.18)

Usefulness/ • Simple, easily available

Advantages • Usually increased in severe TR

• Affected by : RA pressure ; atrial fibrillation

Limitations
; RV relaxation

Interpretation • Usually increased (≥ 1 m/s) in severe TR

ASSESSMENT OF TR SEVERITY
TR jet—CW Doppler
• A full CW Doppler envelope indicates more severe TR than a faint signal

• A triangular CW contour with an early peak velocity indicates elevated RA

pressure or prominent pressure wave in the RA due to severe TR

• The velocity of TR does not reflect the severity of TR

◆ Mild/trivial TR represents a common finding in healthy subjects (65–75%)
and typically has a short colour jet, a low velocity = 1.7–2.3 m/s, with normal
TV appearance and normal RV (Fig. 7.7.19)
◆ Massive TR: often associated with a low jet velocity = near equalization of
RA and RV pressure (< 2 m/s) (Fig. 7.7.20)

◆ Mild TR + severe pulmonary hypertension: possible high velocity jet

• Complete CW Doppler signal difficult to obtain in eccentric jet

 CONSEQUENCES OF TR
2D tricuspid annulus dimensions (Fig. 7.7.22, Box 7.7.2)
• Tricuspid Annulus Diameter (TAD)
• N: 28 ± 5 mm (4CV)

LA size (Figs. 7.6.24D)

• Limitations :
• Underestimation of pressure if inadequate envelope
• Enhanced signal by injecting agitated saline solution
• Simplified Bernoulli equation: not applicable

RV size and function

• RV enlargement is measured by LV diameters (2D diameters, apical 4CV) and/or volumes with 3D-
echo when imaging is of high quality
• dilatation sensitive for chronic significant TR
• normal size almost excludes significant chronic TR
• RV dysfunction is evaluated
• by fractional area change (a value < 32% indicates RV dysfunction)
• RV end-systolic area > 20 cm3 is a marker of poor outcome
• RV ejection fraction is load dependent, often overestimates RV systolic performance and is not
recommended
• Other parameters of RV dysfunction
• TAPSE < 14 mm indicates RV dysfunction (Fig. 7.7.24)
• Peak tissue Doppler tricuspid annulus systolic velocity (s') < 11 cm/s (Fig. 7.7.25)
• TAPSE and Peak Tr s' are less accurate in severe TR
INTEGRATING INDICES OF TR SEVERITY
PERSISTENT OR RECURRENT TR AFTER
LEFT-SIDED VALVE SURGERY
• TR severity/primary aetiology
• RV dysfunction (RV hypokinesia) (Fig. 7.7.26AB)
• Tr annulus dilatation (TAD diast > 40 mm or > 21 mm/m2)
• Reduced TA fraction of shortening (< 25%)
• TV deformation
• Tenting area > 1.63 cm2
• Coaptation distance > 0.76 cm