© 2014, Wiley Periodicals, Inc. DOI: 10.1111/echo.12604

Echocardiography

Clinical Settings Leading to Presystolic Tricuspid Regurgitation  ski, M.D.,* Magdalena Lipczyn  ska, M.D.,† Anna Klisiewicz, M.D.,† and Piotr Hoffman, M.D.† Piotr Szyman *Echocardiographic Laboratory, Valvular Heart Disease Department; and †Adult Congenital Heart Disease Department, Institute of Cardiology Warsaw, Warsaw, Poland

Purpose: Few studies describe diastolic (presystolic) tricuspid regurgitation (DTR) mainly in the context of atrioventricular conduction abnormalities. Little is known about its occurrence in the other clinical settings. Methods: We identified patients with DTR recorded during routine echocardiographic examinations. DTR was defined as low velocity backward flow through the tricuspid valve orifice during enddiastole recorded with a continuous and/or pulsed-wave Doppler and/or color-coded M-mode Doppler echocardiography. Results: Diastolic tricuspid regurgitation was present in a wide variety of clinical entities. Of the 23 patients with DTR 6 patients had ischemic and 10 dilated cardiomyopathy. Others had clinical conditions including: inappropriate pacemaker settings, decompensated hypertrophic cardiomyopathy, biventricular dysfunction following orthotropic heart transplantation, torrential aortic regurgitation, low ejection fraction aortic stenosis, advanced endocardial fibroelastosis, and complex congenital heart disease. Twenty of 23 patients had significantly impaired right ventricle (RV) systolic function. Systolic tricuspid regurgitation was estimated as moderate or severe in 13 cases and mild in the remaining 10 cases. RV systolic pressure was significantly elevated in all but 2 cases. In all but 4 cases DTR was transient. The persistence of DTR was associated with severe pulmonary hypertension, severe biventricular failure, and persistent severe pulmonary regurgitation. Conclusions: Diastolic tricuspid regurgitation may be encountered in a variety of clinical settings and should be sought for especially in patients with advanced RV systolic dysfunction, pulmonary hypertension, pulmonary regurgitation, or conduction abnormalities. Significant systolic regurgitation is not prerequisite for the development of DTR. (Echocardiography 2015;32:19–27) Key words: heart failure, right ventricle, tricuspid regurgitation

Presystolic (diastolic) mitral regurgitation is a well-known phenomenon. It is observed in a subset of patients with atrioventricular (AV) blocks, advanced left ventricular systolic dysfunction, advanced aortic valve disease or hypertrophic cardiomyopathy.1,2 It occurs when AV gradient during end-diastole is reversed. Presystolic mitral regurgitation may be accompanied by presystolic (diastolic) tricuspid regurgitation.3 Few published studies describe presystolic tricuspid regurgitation mainly in the context of AV conduction abnormalities and pacemaker optimization, and little is known about its occurrence in the other clinical settings.4,5 Therefore, the current analysis aimed at identifying other entities predisposing to the development of presystolic tricuspid regurgitation in a case series of patients in whom it Address for correspondence and reprint requests: Piotr Szy ski, M.D., Ph.D., Valvular Heart Disease Department, Instiman tute of Cardiology, Alpejska 42, 04-628 Warsaw, Poland. Fax: ++48 223434501; E-mail: [email protected]

was recognized during routine echocardiographic examinations performed at our laboratory. Methods: We retrospectively identified 23 patients with presystolic tricuspid regurgitation recorded during routine echocardiographic examinations at a tertiary referral center. It was sought by multiple Doppler methods (a continuous and/or pulsedwave Doppler as well as color-coded M-mode Doppler), during routine examinations performed with commercially available Vivid 7 and Vivid 9 ultrasound machines (GE Vingmed Ultrasound, Horten, Norway). Presystolic tricuspid regurgitation was diagnosed when a low-velocity reverse flow toward the right atrium, preceding QRS complex (analogous to electrocardiographic delta wave), was evident on a continuous-wave Doppler tracing and a nonturbulent low-velocity blue-encoded signal of end-diastolic flow to the right atrium was present on a color M-mode 19

 ski, et al. Szyman

Doppler tracing of the right ventricular inflow (four-chamber view) (Fig. 1). No particular instrument settings were necessary to demonstrate diastolic reverse flow, except for low wall filter settings. Persistent presystolic tricuspid regurgitation was diagnosed if it was identified at subsequent echocardiographic examinations (performed at a discretion of a physician in charge). All measurements were performed according to recommendations of the American Society of Echocardiography and/or European Association of Echocardiography. Mitral and tricuspid systolic regurgitation jets were assessed qualitatively according to standard diagnostic criteria and; when feasible, vena contracta as well as effective regurgitant orifices were calculated.6 Presystolic tricuspid regurgitation was assessed in a dichotomous manner, i.e., either present or absent, and no further attempts were made to quantitatively or semiquantitatively assess the degree diastolic jet. Left and right ventricular systolic function was assessed by the measurements of ejection fraction (EF) and fractional area change (FAC), respectively.7,8 Restrictive left ventricular filling was identified based on the characteristic features of Doppler mitral inflow pattern, with a shortened E-wave deceleration time of

Clinical settings leading to presystolic tricuspid regurgitation.

Few studies describe diastolic (presystolic) tricuspid regurgitation (DTR) mainly in the context of atrioventricular conduction abnormalities. Little ...
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