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Comparison of the Echocardiographic and Hemodynamic Diagnosis of Rheumatic Tricuspid Stenosis

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Comparison of the Echocardiographic and Hemodynamic Diagnosis of Rheumatic Tricuspid Stenosis lACC Vol. 3, No.5 1135 May 1984:1135-44 Comparison of the Echocardiographic and Hemodynamic Diagnosis of Rheumatic Tricuspid Stenosis DAVID E. GUYER, MD, LINDA D. GILLAM, MD, RODNEY A. FOALE, MD, MARY C. CLARK, ROBERT DINSMORE, MD, FACC, IGOR PALACIOS, MD, PETER BLOCK, MD, FACC, MARY ETTA KING, MD, ARTHUR E. WEYMAN, MD, FACC Boston, Massachusetts Two-dimensional echocardiography has proved to be reo and right ventricular pressure recordings were consid­ liable in the diagnosis of mitral, aortic and pulmonary ered separately, there was complete agreement between stenosis. Its role in the diagnosis of rheumatic tricuspid the echocardiographic and hemodynamic data. stenosis is still being defined; therefore, the tricuspid Thus, the two-dimensional echocardiogram is a sen­ valve echograms of 147 patients with rheumatic heart sitive and specifictest for diagnosing rheumatic tricuspid disease were examined, Thirty-eight of these patients stenosis. In addition, these data provided an opportunity also underwent hemodynamic evaluation. Tricuspid ste­ to determine the prevalence of tricuspid stenosis in this nosis was defined echocardiographlcally as diastolic an­ group of patients with chronic rheumatic valvular dis­ terior leaflet doming, thickening and restricted excursion ease. Tricuspid stenosis was present in 14 (9.5%) of the of the other two tricuspid leaflets and decreased sepa­ total group of 147 patients who had two-dimensional ration of the leaflet tips. Using these criteria, the sen­ echocardiograms, and in 10 (26.3%) of the 38 who had sitivity and specificityof the echocardiogram In detecting both echocardiographic and hemodynamic studies. In tricuspid stenosis were 69 and 96%, respectively, in the patients with rheumatic heart disease about to undergo group of 38 patients who had both echocardiographic cardiac catheterization, an echocardiographicstudyshould and hemodynamicevaluations.However,whenthe smaller prove useful in making the diagnosisof tricuspid stenosis. group of 17 patients who had simultaneous right atrial Rheumatic tricuspid valve stenosis is a chronic disorder cardiac output despite successful surgical relief of the left­ characterized by scarring and fibrosis of the tricuspid valve sided valvular disease (2,8). leaflets, fusion of the leaflet commissures and associated Currently, the diagnosis of tricuspid stenosis is difficult. fibrosis and thickening of the chordae tendineae (1-4). These It is easily overlooked clinically because the characteristic combine to limit leaflet mobility and reduce the size of the physical signs are frequently masked by the concurrent mi­ tricuspid orifice, thereby obstructing right ventricular filling. tral stenosis (5-7,9, 10,12.13). The hemodynamic diagnosis Tricuspid stenosis has been reported to occur in 3 to 22% of tricuspid stenosis often depends on the accurate mea­ of patients with rheumatic mitral valve disease, and it vir­ surement of a small pressure gradient, is complicated by tually never occurs in the absence of mitral stenosis (4-10). the common association of tricuspid regurgitation and atrial When mitral disease is accompanied by tricuspid stenosis, arrhythmias and requires precise simultaneous pressure re­ the mitral lesion is typically more severe and predominates cordings from the right atrium and right ventricle (14-16), clinically (4,8,9, II). Detection ofconcomitant tricuspid ste­ Simultaneous right-sided recordings are not routine in many nosis is important, however, because a tricuspid lesion may hemodynamic laboratories because they may extend the overall lead to chronic elevation of right atrial pressure and low length of the catheterization and necessitate the insertion of an additional catheter; thus. they are often omitted unless From the Massachusetts General Hospital, Cardiac Ultrasound Labo­ tricuspid stenosis is suspected before the study, ratory, Boston, Massachusetts. Manuscript received February 28,1983: Since 1955, M-mode echocardiography has been used revised manuscript received November 14, 1983, accepted November 22, extensively to noninvasively diagnose valvular heart disease 1983. Address for reprints: Arthur E. Weyman, MD, Massachusetts General ( 17). Although this technique has proven reliable in de­ Hospital, Cardiac Ultrasound Laboratory, Boston, Massachusetts 02114. tecting mitral stenosis. its ability to diagnose rheumatic tri- © 1984 by the American College of Cardiology 07.'S-I097/X4!S300 11 36 GUYER ET AL. JACe Vol. 3. No.5 DIAGNOSISOF TRICUSPIDSTENOSIS May 1984:11 35- 44 cuspid stenosis remains in doubt (18 ,19). Two-dimensional ration and motion have not been clearly established, 20 echocardiography has been demonstrated to be a sensitive normal patients were also examined echocardiographically method for detecting stenotic lesions of the mitral, aortic to define these patterns. The group of normal subjects con­ and pulmonary valves (20-22), and has been shown to be sistedof healthy volunteers with no history or physical find­ capable of directly visualizing the mitral valve orifice and ings suggestive of cardiac disease. In this reference group, quantifying the stenotic valve area (20,23-25). In addition, the meanage was 30 years (range 26 to 50) and seven (35%) it has been used to document tricuspid valve involvement were women. These patients did not undergo cardiac in Loeffler's endocarditis and carcinoid heart disease (26,27). catheterization. Two recent studies ( 19,28) have suggested that it is a sen­ sitive and specific test for detecting rheumatic tricuspid ste­ Study Protocol nosis. Its predictive value in detecting tricuspid stenosis, Hemodynamic data. The 38 study patients underwent however, varied enormously in these studies (100 versus both right and left heart catheterization. Pressures were mea­ 21%) raising questions as to the true accuracy of the method sured using fluid-filled catheters and Hewlett-Packard 1290 and the appropriate two-dimensional echocardiographic cri­ C transducers, and were recorded on a Hewlett-Packard teria for diagnosing tricuspid stenosis. strip-chart recorder. Mitral and aortic valve areas were cal­ The purpose of our study was to examine the role of the culated using the Gorlin formula (30) . In 17 patients, si­ two-dimensional echocardiographic technique in the diag­ multaneous right atrial and right ventricular pressures were nosis of rheumatic tricuspid stenosis in a larger patient group recorded. and a hemodynamic diagnosis of tricuspidstenosis than previously studied, to define in more detail the con­ was made if there was any difference between diastolic right fi guration and motion of the tricuspid valve associated with atrial and right ventricular pressures as determined by plan­ hemodynamically significant tricuspid stenosis and to com­ imetry of the pressure curves. There were 21 patients in pare the sensitivity and specifi city of the echocardiographic whom the presence of a gradient between mean right atrial diagnosis with the two common hemodynamic methods for and right ventricular diastolic pressures was assessed by detecting right ventricular inflow gradients. catheter pullback. Tricuspid regurgitation was identified in all patients by the presence of systolic waves in the right Methods atrial pressure tracing (31.32). Patients Echocardiographic studies. Echocardiographic exam­ inations were performed using either a Smith-Kline Instru­ Patient selection. To identify a group of patients with ments Ekosector 10 or an Advanced Technology Labora­ rheumatic valvular disease, the echocardiographic records tories Mark III mechanical scanner. Complete two­ of the 2.660 patients examined at the Massachusetts General dimensional echocardiographic examinations were per­ Hospital between July I, 1980 and August I, 1981 were formed on all patients. The specific tomographic planes used reviewed. Patients were considered to have chronic rheu­ to examine the tricuspid valve were: I) the parasternal long­ matic valvular disease if they had a history of rheumatic axis view of the right ventricular inflow tract; 2) the apical carditis and echocardiographic evidence of any valvular scarring, or if they displayed a pattern of rheumatic mitral four chamber view, optimized to record the left ventricular stenosis with or withoutother valvular abnormalities. There apex and maximal excursion of the mitral and tricuspid valve were 147 patients who met these criteria. Of these patients, leaflets; and 3) the subcostal long-axis view. optimized to 38 had undergone full cardiac catheterization within I year record the right ventricular long-axis and maximal tricuspid of the echocardiographic examination. These 38 patients leaflet excursion (33). Echocardiograms were recorded on formed the defin ed study group for this report. magnetic tape and reviewed on an Easy View II off-line Study patients. Some pertinent characteristics of the system (Microsonics, lnc.) in real-time and in a frame by study patients are given in Table I. Their ages ranged from frame mode. 33 to 76 years (mean 60.4 ) and 29 (76%) were women. All Definition of tricuspid stenosis. This was considered to had mitral stenosis; 25 (66%) also had mitral regurgitation. be present echocardiographically if the following three cri­ There were II (29%) with aortic stenosis and 12 (32%) with teria were met: I) the anterior tricuspid valve leaflet domed aortic insuffi ciency. No patient had hemodynamic evidence in diastole; that is, there was apparent restriction of leaflet of pulmonary stenosis. Thirty patients (79%) had pulmonary
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