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Ann Thorac Surg 1998;66:2044-2050
© 1998 The Society of Thoracic Surgeons

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Original Articles

Influence of functional tricuspid regurgitation on right ventricular function

^a Division II, Department of Surgery, Kobe University School of Medicine, Kobe, Japan

Accepted for publication June 12, 1998.

Address reprint requests to Dr Sugimoto, Division II, Department of Surgery, Kobe University School of Medicine, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan

	Abstract

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Background. Although right ventricular (RV) function has been extensively studied during the past decade, few reports have described the influence of functional tricuspid regurgitation (TR) on RV function.

Methods. One hundred forty-two patients with left-side valvular heart disease associated with TR were enrolled in the study and divided into three groups according to tricuspid annular diameter: group 1 (n = 66), tricuspid annular diameter less than 40 mm; group 2 (n = 58), tricuspid annular diameter of 40 to 50 mm; and group 3 (n = 18), tricuspid annular diameter greater than or equal to 50 mm. In groups 2 and 3, the right heart parameters had deteriorated to the point that TR repair was necessary. The mean follow-up period was 102 months after the operation.

Results. In each of the three groups, as pulmonary arteriolar resistance index increased, RV forward stroke work index increased in a linear fashion. The slope of the linear regression line was progressively less in group 1, 2, and 3 preoperatively. Postoperatively, this line moved in a parallel manner in group 1 and became steeper in group 2, consequently becoming similar in both groups. However, in group 3, although the slope became steeper in spite of a remarkable decrease of TR, it remained less when compared with groups 1 and 2. In addition, the right heart parameters also improved, but still remained worse in group 3 than group 2; 7 patients undergoing a flexible annuloplasty have shown gradual aggravations in TR and late postoperative clinical manifestations.

Conclusions. Functional TR with severely dilated annulus may produce an irreversible deterioration of RV function. The preoperative relationship between pulmonary arteriolar resistance index and RV forward stroke work index, that is, RV systolic function to pressure afterload, might predict a postoperative fate of the right heart function.

	Introduction

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It has not been clearly determined whether right ventricular (RV) function impaired by functional tricuspid regurgitation (TR) is reversible [1]. Although RV function has been extensively studied during the past decade [2–8], few reports have described the changes in RV hemodynamics after TR repair. Recently, greater attention has been paid to RV function because its dysfunction may affect postoperative prognosis. However, a definitive index to evaluate RV function has not been described. In the present study, we reviewed a change of the RV function after valve operations using right heart catheterization and echocardiographic studies.

	Material and methods

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Patients
From April 1980 to September 1996, 372 patients underwent valve operations for acquired valvular heart disease. Among them, 102 patients who had an organic TR, or who underwent only aortic valve operation or concomitant cardiac procedures such as coronary artery bypass grafting, were excluded from the study. Ten patients who died of cardiac complications early postoperatively and 20 patients who had a repeat operation because of early or late dysfunction of the left-side valve repairs were also excluded from the study. Twenty-eight patients who were lost to follow-up or did not undergo preoperative or postoperative catheterization study were also excluded from the study. Of the remaining patients, 142 patients (58 men and 84 women) who had mitral valve lesion or mitral and aortic valve lesions associated with functional TR were enrolled in the study. The main left-side lesions were mitral stenosis in 80 patients and mitral regurgitation in 38 patients. Twenty-four patients had mitral as well as aortic valve lesions. Open mitral commissurotomy was performed in 12 patients, mitral valve replacement in 106 patients, open mitral commissurotomy and aortic valve replacement in 4 patients, and combined mitral and aortic valve replacement in 20 patients.

Evaluation of tricuspid regurgitation
Before March 1985, TR was evaluated using right ventriculography and contrast echocardiography. Since April 1985, the following Doppler study has been used [9]. Echocardiographic study was performed within 5 days before the operation when the patients were hemodynamically stable. Two-dimensional and Doppler echocardiography were performed using Toshiba SSH-65A and SSH-140A equipment with a 2.5 MHz transducer. The TR jet was observed in the following three cross-sectional views: parasternal long-axis view of the right ventricular inflow tract, apical four-chamber view, and parasternal short-axis view at the level of the aortic valve. The method for calculating TR volume per beat (V_TR) was previously reported [9]. Tricuspid regurgitation was first observed in the two right-angle cross-sectional views using two-dimensional color Doppler echocardiography. The cross-sectional area (S) of the base of the TR jet was calculated with each width of the base of the TR jet. Next, a continuous-wave Doppler echocardiogram was recorded from the center of the base of the TR jet. The TR volume of one unit area (Vu) was calculated by integrating the parabolic flow velocity signal of the continuous-wave Doppler echocardiogram during the ejection phase. The V_TR, which is assumed to build up a conical shape, is equal to the product of the cross-sectional area of the base of the TR jet and the TR volume of one unit area ( ) (Appendix 1).

The tricuspid annular diameter (TAD) at end-diastole was measured from the above three cross-sectional views and was determined in the view that showed the maximal value.

Catheterization study
All patients underwent preoperative right heart catheterization studies including cineangiography at the same time of the Doppler studies. All patients were also studied between 1 and 2 months after operation. In this series, RV stroke work index (RVSWI) and pulmonary arteriolar resistance index (PARI) were also obtained in addition to the routine pressure study using a Swan-Ganz catheter. The right ventricular end-diastolic volume (RVEDV) index, end-systolic volume (RVESV) index, and ejection fraction (RVEF) were obtained from the biplane cineangiograms by the area-length method [10] on an average of five heart beats excluding premature contractions. The RVSWI was calculated using the stroke volume from RVEDV minus RVESV. In addition, the forward RV stroke volume was also obtained from the cardiac output divided by the pulse rate, and RV forward stroke work index (RVFSWI) was calculated using this value. In this calcuation, the cardiac output was obtained by the Fick method to eliminate the influence of TR (Appendix 1).

Other parameters
The degree of heart failure was based on New York Heart Association (NYHA) functional class, and degree of hepatomegaly and indocyanine green measurement were also evaluated.

Treatment of tricuspid regurgitation
All patients were divided into three groups according to preoperative TAD: group 1 (n = 66), TAD less than 40 mm; group 2 (n = 58), TAD at least 40 mm but less than 50 mm; group 3 (n = 18), TAD at least 50 mm. The V_TR was 0 to 11 mL (mean, 5.3 ± 2.3 mL) in group 1, 9 to 27 mL (mean, 14.6 ± 3.2 mL) in group 2, and 23 to 40 mL (mean, 29.0 ± 6.5 mL) in group 3. In groups 2 and 3, the degree of hepatomegaly, the k value of the indocyanine green measurement, right atrial mean pressure, RV end-diastolic pressure, RVEDV index, and RVESV index had deteriorated to the point that surgical repair for TR was necessary (Fig 1). All patients underwent complete repairs for the left-sided valvular lesions. Tricuspid regurgitation was ignored in group 1. In group 2, 45 patients underwent Kay’s annuloplasty [11], and 13 patients underwent a modified DeVega’s annuloplasty [12, 13]. In group 3, Kay’s annuloplasty was performed for 3 patients, a modified DeVega’s annuloplasty for 4 patients, annuloplasty using Carpentier ring [14] for 5 patients, and tricuspid valve replacement [15] for 6 patients. In the patients undergoing tricuspid valve replacement, the tricuspid cusps showed slightly degenerative changes caused by a long-standing severe TR. Mechanical (St Jude Medical) or bioprosthetic valves (Carpentier-Edwards pericardial valves) were used in 3 patients each.

View larger version (22K): [in this window] [in a new window]   Fig 1. Preoperative right heart parameters. In groups 2 and 3, the right heart parameters had deteriorated to the point that tricuspid regurgitation repair was necessary. Group 1: preoperative tricuspid annular diameter (TAD) at end-diastole <40 mm; group 2: TAD = 40 to 50 mm; group 3: TAD 50 mm. Values are expressed as the mean ± standard deviation. (ICG(k) = k value of indocyanine green measurement; RAm = right atrial mean pressure; RVEDP = right ventricular end-diastolic pressure; PAm = pulmonary arterial mean pressure; RVEDVI = right ventricular end-diastolic volume index; RVESVI = right ventricular end-systolic volume index; RVEF = right ventricular ejection fraction; *p < 0.05.)

Statistical analysis
Statistical analysis was performed with the use of the Stat View 4.11 software package (Abacus Concepts, Inc, Berkeley, CA). For comparisons between three groups, we used analysis of variance, including post hoc comparisons with the Fisher’s protected least significant difference test. When observations from only two values were available for comparison, we used unpaired or paired Student’s t test. Values are expressed as the mean plus or minus standard deviation. Significance was defined as p less than 0.05.

	Results

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Relationship between pulmonary arteriolar resistance index and right ventricular forward stroke work index in each group
In each of the three groups, as PARI (x axis) increased, RVFSWI (y axis) increased in a linear fashion both preoperatively and postoperatively. The slope of the linear regression line was progressively gentler in group 1 ( , r = 0.81, p < 0.0001), group 2 ( , r = 0.84, p < 0.0001), and group 3 ( , r = 0.86, p < 0.0001) preoperatively (Fig 2). Postoperatively, the linear regression line moved parallel and to the right in group 1 ( , r = 0.85, p < 0.0001), and the slopes became much steeper in group 2 ( , r = 0.82, p < 0.0001) and a little steeper in group 3 ( , r = 0.85, p < 0.0001) (Fig 3). As a result, the slopes of the lines became similar between groups 1 and 2, but remained gentler in group 3 (Fig 4).

View larger version (16K): [in this window] [in a new window]   Fig 2. Preoperative correlation between pulmonary arteriolar resistance index (PARI, x axis) and right ventricular forward stroke work index (RVFSWI, y axis) in each of the three groups. As PARI increased, RVFSWI increased in a linear fashion. The slope of the regression line was gentler in groups 1, 2, and 3 in that order.

View larger version (15K): [in this window] [in a new window]   Fig 3. Change of correlation between pulmonary arteriolar resistance index (PARI) and right ventricular forward stroke work index (RVFSWI) after operation in each of the three groups. The regression line moved parallel in group I (a), and the slopes became steeper in groups 2 (b) and 3 (c).

View larger version (16K): [in this window] [in a new window]   Fig 4. Postoperative comparison of the regression lines correlating pulmonary arteriolar resistance index (PARI) and right ventricular forward stroke work index (RVFSWI) among the three groups. The slope of regression line became similar in groups 1 and 2, but still remained gentler in group 3.

View larger version (13K): [in this window] [in a new window]   Fig 5. Changes of the ratio of right ventricular forward stroke work index to pulmonary arteriolar resistance index (RVFSWI/PARI) values after operation (Postop) in each group. The RVFSWI/PARI value was significantly lower in group 3 compared with groups 1 and 2 preoperatively (Preop). Postoperatively, this value showed a significant decrease in group 1, a significant increase in group 2, and no significant change in group 3. Values are expressed as the mean ± standard deviation. (*p < 0.05.)

In group 2, all patients had a remarkable decrease in TR immediately after repair using Kay’s or a modified DeVega’s annuloplasty, and never had a redevelopment late postoperatively (mean V_TR, 1.8 ± 1.9 mL). The degree of hepatomegaly, right atrial mean pressure, RV end-diastolic pressure, RVEDV index, and RVESV index significantly improved, as did the NYHA functional class (Fig 6).

View larger version (33K): [in this window] [in a new window]   Fig 6. Changes of right heart parameters after tricuspid regurgitation repair. The right heart parameters significantly improved, but values in group 3 remained worse compared with group 2. Values are expressed as the mean ± standard deviation. (NYHA = New York Heart Association; RAm = right atrial mean pressure; RVEDP = right ventricular end-diastolic pressure; RVEDVI = right ventricular end-diastolic volume index; RVESVI = right ventricular end-systolic volume index; *p < 0.05.)

	Comment

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Assessment of left ventricular function has been already established by various evaluation methods. Recently, greater attention has been paid to RV function because it is believed to affect the postoperative prognosis. However, assessment of RV function has been hampered by difficulty measuring instantaneous RV volume [8]. This problem results from the fact that the crescent of RV geometry confounds the use of many techniques established for estimation of left ventricular volume. Methods described for calculation of RV volume from multiple linear dimensions or from spatial relations of implanted markers are laborious and not easily reproduced [3]. We have used the area–length method for measuring RV volume by contrast ventriculography, although it is not so reliable for measuring the instantaneous RV volume.

We retrospectively searched for a simple index for RV function from the usual catheterization data, and found relationships between PARI and RVFSWI, that is, RV systolic function to pressure afterload. In calculation of RVFSWI, cardiac index from the Fick method is easily estimated and well reproducible. As PARI (x axis) increased, RVFSWI (y axis) also increased in a linear fashion, and the slope of the linear regression line was gentler along with the severity of TR preoperatively. This is considered to be related to the fact that RV forward stroke volume decreases in proportion to the increase of TR. In fact, the regression line moved parallel and to the right in group 1 (insignificant TR) because of regression of RV pressure overload after left-sided valve repair, and the slope became steeper in group 2 (moderate TR) because of remarkable regression of TR after concomitant TR repair. As a result, the regression lines became similar between both groups. However, in group 3 (severe TR), although the slope of the linear regression line became steeper in spite of a remarkable decrease of TR, it remained still gentler when compared with groups 1 and 2. In addition in this group, the right heart parameters also improved but remained worse than the values in the other groups, and some patients undergoing such a flexible annuloplasty as Kay’s or a modified DeVega’s one has showed gradual aggravations of clinical manifestations along with redevelopment of TR late postoperatively. This fact indicates that the RV function had been irreversible in group 3 because of a long-standing severe TR.

Regarding the usefulness of RVFSWI, this value was easily obtained from the usual catheterization study and showed a higher reproducibility than the RVSWI using cineangiography. In fact in this series, RV stroke volume derived from RVEDV minus RVESV was not reproducible; therefore, no relationships were found between PARI and RVSWI. In addition, the RV backward stroke work, representing stroke work of TR, could be ignored because TR was a buffer of RV pressure overload. Especially in association with mitral valve lesion, right atrial pressure was far lower than pulmonary arterial pressure. The preoperative value of RVFSWI/PARI x 1,000 was estimated in this study, and the result in Figure 5 indicated that a value of approximately 17 was considered to be a boundary indicating whether irreversible right heart dysfunction was present. In the future, the preoperative value of RVFSWI/PARI might be a predictive parameter for postoperative fate of the right heart function.

	Appendix 1. Calculations of parameters

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Calculation of TR volume per beat (V_TR):

1. Two-dimensional Doppler echocardiography Cross-sectional area of base of TR: (a, b: each width of the base of the TR jet in the two right-angle cross-sectional views.)
   

1. Continuous-wave Doppler echocardiogram Regurgitant volume of one unit area at base of TR:
   

(v: peak velocity, t: duration of regurgitation.)

1. (V_TR is equal to the sum of the Vu per S, which is assumed to build up a conical shape.)
   

Pulmonary arteriolar resistance index:

Right ventricular forward stroke work index:

*Right ventricular stroke work index: RVSWI = (PAm - RAm) x SI x 0.0136 (PAm = pulmonary arterial mean pressure; PCm = pulmonary arterial wedge mean pressure; CI = cardiac index by Fick’s method; HR = heart rate; SI = stroke index obtained from biplane angiograms.)

	References

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