Nosheen Reza, MD Profile picture
Jul 22, 2018 12 tweets 18 min read Twitter logo Read on Twitter
#FITSurvivalGuide: The Forgotten Valve-#TricuspidRegurgitation (#TR) #tweetorial for the new #ACCFIT!

1⃣ Anatomy
2⃣ Etiologies
3⃣ Classification
4⃣ Diagnosis
5⃣ Treatment

Resources: @ASE360 @JACCJournals @CircAHA @ACCCardioEd @UMNews @Medtronic

cc: @dr_chirumamilla
[2/10] Impt to understand #TricuspidValve 1⃣ Anatomy

3 leaflets ⬇️ + fibrous annulus + 2 papillary 💪🏽 + chordae tendinae + RA/RV ❤️

⬛️ Anterior 🍃 (largest)
▪️Septal (smallest)

(note: throughout #tweetorial, see image descriptions for more content) TV is largest and most apically displaced valve (normal TV area is between 7 and 9 cm^2).  Tricuspid annulus = complex nonplanar 3D structure w/low posteroseptal portion (towards the RV apex) & high anterolateral portion.TV has 2 distinct pap muscles (ant & post) + 3rd variable septal pap muscle. Largest pap = typically anterior w/chordae supporting ant & post leaflets. Posterior pap supports post + septal leaflets. Septal pap is variable: absent in up to 20% of normal patients or small, or multiple.Note attachments of leaflets/chordae to papillary muscles, RV free wall, moderator band.
[3/10] 2⃣ Etiologies = Structural (1º) vs. Functional (FTR)

Keep chart ⬇️ DDx in mind when reading #EchoFirst

~80% of significant TR = FTR/2º to TA dilatation + leaflet tethering ⬅️ RV remodeling ⬅️ volume and/or pressure overload

Structural (1º) cause = less common
[4/10] 3⃣ Classification
Exam 🧐:
✅ Elevated “c-V” waves in JVP
✅ Systolic murmur at LSB that ⬆️ w/inspiration
✅ Pulsatile liver edge, hepatomegaly, ascites

🚨 Murmur can be absent even in advanced TR!

Sx 😷: fatigue, abd fullness, edema, palps (if +AF)

⬇️ from @NEJM
[5/10] 3⃣ Classification

2014 @ACCinTouch @AHAScience Valve Guidelines:
🔹Stage A = risk of TR
🔹Stage B = progressive TR
🔹Stage C = asymptomatic severe TR
🔹Stage D = symptomatic severe TR

Severe isolated TR a/w excess mortality & morbidity
[6/10] 4⃣ Diagnosis

CXR & ECG ➡️ RV/RV dilation

Dx standard = #EchoFirst for
🔸TR severity/etiology
🔸Chamber size & fxn (#whyCMR can help here, too)
🔸Hepatic venous flow
🔸Left ❤️ disease
[7/10] 4⃣ Diagnosis
Be mindful 🤔 of your imaging view/modality limitations!

Characterizing TR severity needs *integrative* assessment of multiple qualitative+quantitative parameters

Great read: @ASE360 Guidelines for Right Heart Echo Assessment:
[8/10] 5⃣ Treatment

Stage D:
◽️Diuretics can be useful
◽️Loop diuretics typical
🚨 Aggressive diuresis can ⬇️ LVSV and CO

Stages C/D, severe FTR:
◾️Consider other medical therapies to down arrow PASP and/or PVR
◾️Specific pulmonary vasodilators may help in #cvPH
[9/10] 5⃣ Treatment
TV repair or replace: severe TR a/w Sx or RV dysfxn despite 💊

TV replace: bioprosthetic & mechanical options

TV annuloplasty: indicated in severe FTR undergoing left-sided surgery

Transcatheter/percutaneous options being used & developed – more to come!
[10/10] That’s it for the #TR #FITSurvivalGuide! Please add what I missed!

Tons of great reads out there-in addition to those in tweets:
@JACC 2015
@Circ 2016
@Lancet 2016
@ESC 2017
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