Penn Medicine cardiovascular imaging specialist Tiffany Chen, MD, discusses the role of imaging in tricuspid valve disease with a focus on pre-procedural imaging.
Related Links: Dr. Chen's physician profile
Hi I'm Tiffany Chen I'll be discussing imaging of the trick. A spit valve. These are my disclosures. What is the role of imaging and custom valve disease? Um Well imaging involves multiple tools including echo C. T. And M. R. I. In order to assess the Oculus and valve anatomy, identify the mechanism of tR quantify the severity of TR and also to evaluate the RV function. Although we'll be discussing mostly pre procedural imaging imaging is also um important for inter procedural guidance and post procedural assessment following tricastin intervention. Try custom valve leaflets are classically thought to involve three leaflets, antiseptic and post your leaflets. However, more recent studies have shown that there can be anywhere from 2 to 6 leaflets. In fact in almost half of patients studied in this large cohort had in fact two or four leaflets. No the complexity and the variability in um leaflet configuration makes two dimensional imaging by echocardiography of the track leaflets um complicated and um dependent on the angular ation of the imaging sector. So this is where three dimensional imaging can be particularly helpful and um understanding the valve leaflet orientation in anatomy. Um And we can incorporate this in both transfer asic eco um as well as in transit soft shell eco in which the trans gastric short access views can also show leaflet anatomy on two dimensional imaging. In addition to your custom leaflets. Um we also have to assess the triggers. But analysts, unlike the mitral valve, the trusted analyst is a somewhat of a misnomer is not a distinct fiber structure but it's also elliptical um non cleaner and and highly dynamic throughout the cardiac cycle dependent on loading conditions. What about assessing the mechanism of tr well, T. R. Can occur because of primary causes or be secondary to RV dysfunction or right atrial remodeling. Another cause of tR um is whether it has to do with uh case maker or I. C. D. Needs um Many patients with these uh leads do have significant tr um and prayers, careful imaging in order to assess the significance and the interaction with the leaf those um In this echo study it was shown that um many of the patients with icy leads um have leads located in Commissioners or in the middle of the track perennials and thus not necessarily a primary cause of tr other imaging clues for the mechanism of TR. We can look at the degree of leaflet tethering and restriction as well as um right atrial and right ventricle rehabilitation. Um and remodel um as a reminder. These are these are the stages of tr um as it progresses regardless of the cause. Um and um imaging can offer us clues into where a patient might be um in this uh staging algorithm in terms of quantification of tR um by echo. It is a multi parametric approach that incorporates a variety of quantitative and semi quantitative Doppler parameters um including color flow. Doppler Pisa method special Doppler looking for secondary signs such as hepatic vein reversal um As well as using some newer techniques including three D. Color Doppler in order to measure being a contracted area because of the late presentation of many patients with functional tr. There's a new grading scheme that has been recently proposed um with two uh more classifications of tr beyond severe and these are called massive and torrential um with some thresholds and examples that you see here um T. E. For trade cusp. It um involves comprehensive imaging using soft doing trans gastric views um in order to study the TR jet as well as Detroit spit valve anatomy. Now what about other imaging techniques? Um cardiac M. R. I can be complementary to echocardiography on the power of CMR is in its volumetric quantification of of tR um based on phase contrast imaging, both two D. And four D. Flow um As well as the ability to quantitative um R. V. Volumes and assess for um remodeling such as fibrosis based on late gadolinium enhancement. Cardiac cT is also an important tool for imaging the valve um predominantly for assessing anatomy um and is used uh mostly for annular segmentation. Um and sizing considerations for procedural planning. Um However um as you can see here cardiac cT offers very high spatial resolution um for looking for classification as well as imaging the sub valvular apparatus. Additionally, cardiac ct can be helpful for um procedural planning um that may be a device specific um but allows us to predict uh forest topic angles to facilitate the procedure um as well as to simulate delivery catheters um and um uh facilitate three D. Printing um of heart models for particularly complex cases. So in summary trade custody valve anatomy is complex and variable. Um There can be dramatic pathological modeling changes um that may subsequently reveal the mechanism and severity of tr um By imaging imaging should be integrated and may require multiple modalities um including some advanced techniques such as three D. C. T. And M. R. I. Um And that finally we should not forget to evaluate the right ventricle in consideration of try custom valve intervention. With that I'd like to thank you for your attention. We'll take any questions.
