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(Circulation. 2009;120:1091-1098.)
© 2009 American Heart Association, Inc.

Imaging

Real-Time 3-Dimensional Echocardiography Provides New Insight Into Mechanisms of Tricuspid Valve Regurgitation in Patients With Hypoplastic Left Heart Syndrome

K. Takahashi, MD; A. Inage, MD; I.M. Rebeyka, MD; D.B. Ross, MD; R.B. Thompson, PhD; A.S. Mackie, MD; J.F. Smallhorn, MBBS

From the Departments of Pediatrics, Surgery and Biomedical Engineering, University of Alberta, and Stollery Children’s Hospital Edmonton, Alberta, Canada.

Correspondence to Jeffrey F. Smallhorn, MBBS, University of Alberta Hospital, Room 4C2, Walter C. Mackenzie Health Sciences Centre, Edmonton, Alberta, T6G 2B7, Canada. E-mail jeffrey.smallhorn{at}capitalhealth.ca

Received July 23, 2008; accepted June 19, 2009.

Background— Tricuspid regurgitation in hypoplastic left heart syndrome has an impact on outcome, but its mechanisms remain unclear.

Methods and Results— Real-time 3-dimensional echocardiography was performed in 35 patients with hypoplastic left heart syndrome (age, 1 month to 10 years; 10 after first-stage Norwood, 12 after superior cavopulmonary shunt, 13 after Fontan). From the 3-dimensional data set, we marked the annulus in systole and diastole. At mid systole, we marked the location of the papillary muscle tip and point of chordal attachment to the leaflet. We traced the surfaces of the tricuspid valve leaflets and measured the volume of leaflet prolapse, tethering, annular and septal leaflet areas, and papillary muscle position. Seventeen patients had moderate tricuspid regurgitation (prolapse, 7; tethered leaflets, 7) and 18 mild (prolapse, 0; tethered leaflets, 7). Multiple linear regression analysis revealed that moderate tricuspid regurgitation is associated with leaflet tethering and prolapse; that in hypoplastic left heart syndrome with tethered leaflets, the papillary muscle is displaced laterally and the tricuspid annulus is more planar; and that enlargement of the annulus at mid systole, small septal leaflet area, and age affect the degree of prolapse.

Conclusion— In hypoplastic left heart syndrome, moderate tricuspid regurgitation may be associated with increasing age, geometrical changes of the annulus, leaflet prolapse, lateral papillary muscle displacement, and subsequent leaflet tethering, as well as a smaller septal leaflet.

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CLINICAL PERSPECTIVE

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Clinical Summaries
Circulation 2009 120: 1021-1023. [Extract] [Full Text]