Characteristics and Significance of Tricuspid Valve Prolapse in a Large Multidecade Echocardiographic Study

Published:October 15, 2020DOI:https://doi.org/10.1016/j.echo.2020.09.003

      Highlights

      • TVP is rare on transthoracic echocardiography and of uncertain significance.
      • Over 18 years, sTVP was present in 0.3% of individuals.
      • Seventy-five percent of those with TVP had associated MVP.
      • Leaflet AD > 2 mm in the PSAX view best defined TVP.
      • TVP was associated with more TR and clinically significant MVP.

      Background

      Characteristics of tricuspid valve prolapse (TVP) on transthoracic echocardiography are not well defined. As tricuspid valve interventions are increasingly considered, information on the definition and clinical significance of TVP is needed.

      Methods

      At the authors' institution, between January 26, 2000, and September 20, 2018, 410 patients (0.3%) were determined to have suspected TVP. These transthoracic echocardiograms and those of 97 age- and sex-matched normal control subjects were reviewed. Interrater agreement on TVP by visual inspection was assessed in a blinded subset. Leaflet atrial displacement (AD) > 2 SDs above the mean in normal control subjects was used to identify an empiric definition of TVP Features of patients meeting this definition were evaluated.

      Results

      Three hundred twelve transthoracic echocardiograms with available and interpretable images (76.1%) were included. Interrater agreement on TVP diagnosis by visual inspection was moderate. Normal values of AD were up to 4 mm in the right ventricular inflow view and 2 mm in all other views. AD > 2 mm in the parasternal short-axis view had the best accuracy against suspected TVP to identify TVP. Those with TVP by this definition more frequently had 3 to 4+ tricuspid regurgitation (22.2% vs 3.1%; P < .001), mitral valve prolapse (MVP; 75.0% vs 3.1%; P < .001), and more clinically significant MVP (greater prevalence of 3 to 4+ mitral regurgitation). No difference in mortality was observed in those with isolated TVP versus TVP and MVP (log-rank P = .93).

      Conclusions

      In the largest study of TVP to date, interrater agreement on TVP diagnosis by visual inspection was moderate. A cutoff of >2-mm AD in the parasternal short-axis view was optimal to define TVP. Those with TVP by this definition had more significant tricuspid regurgitation, larger right ventricles, and more clinically significant MVP. Overall, these results suggest an increased role for surveillance for TVP and the need for clear diagnostic criteria in updated guidelines.

      Keywords

      Abbreviations:

      4CH (Apical four-chamber), AD (Atrial displacement), BIDMC (Beth Israel Deaconess Medical Center), eTVP (Empiric tricuspid valve prolapse), MR (Mitral regurgitation), MVP (Mitral valve prolapse), PSAX (Parasternal short-axis), RVI (Right ventricular inflow view), sTVP (Suspected tricuspid valve prolapse), TR (Tricuspid regurgitation), TTE (Transthoracic echocardiogram), TVP (Tricuspid valve prolapse)
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      References

        • Tei C.
        • Shah P.M.
        • Cherian G.
        • Trim P.A.
        • Wong M.
        • Ormiston J.A.
        Echocardiographic evaluation of normal and prolapsed tricuspid valve leaflets.
        Am J Cardiol. 1983; 52: 796-800
        • Brown A.K.
        • Anderson V.
        Two dimensional echocardiography and the tricuspid valve. Leaflet definition and prolapse.
        Br Heart J. 1983; 49: 495-500
        • Mardelli T.J.
        • Morganroth J.
        • Chen C.C.
        • Naito M.
        • Vergel J.
        Tricuspid valve prolapse diagnosed by cross-sectional echocardiography.
        Chest. 1981; 79: 201-205
        • Sasse L.
        • Froelich C.R.
        Echocardiographic tricuspid prolapse and nonejection systolic click.
        Chest. 1978; 73: 869-870
        • Karayannis E.
        • Stefadouros M.A.
        • Abdulla A.M.
        • Blackwell J.C.
        Use of echocardiography in the diagnosis of prolapsed tricuspid valve.
        J Med Assoc Ga. 1978; 67: 205-208
        • Maranhao V.
        • Gooch A.S.
        • Yang S.S.
        • Sumathisena D.R.
        • Goldberg H.H.
        Prolapse of the tricuspid leaflets in the systolic murmur-click syndrome.
        Cathet Cardiovasc Diagn. 1975; 1: 81-90
        • Horgan J.H.
        • Beachley M.C.
        • Robinson F.D.
        Tricuspid valve prolapse diagnosed by echocardiogram.
        Chest. 1975; 68: 822-824
        • Chandraratna P.N.
        • Lopez J.M.
        • Fernandez J.J.
        • Cohen L.S.
        Echocardiographic detection of tricuspid valve prolapse.
        Circulation. 1975; 51: 823-826
        • Mutlak D.
        • Khoury E.
        • Lessick J.
        • Kehat I.
        • Agmon Y.
        • Aronson D.
        Lack of increased cardiovascular risk due to functional tricuspid regurgitation in patients with left-sided heart disease.
        J Am Soc Echocardiogr. 2019; 32: 1538-1546
        • Anwar A.M.
        • Geleijnse M.L.
        • Soliman O.I.
        • McGhie J.S.
        • Frowijn R.
        • Nemes A.
        • et al.
        Assessment of normal tricuspid valve anatomy in adults by real-time three-dimensional echocardiography.
        Int J Cardiovasc Imaging. 2007; 23: 717-724
        • Lang R.M.
        • Badano L.P.
        • Mor-Avi V.
        • Afilalo J.
        • Armstrong A.
        • Ernande L.
        • et al.
        Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging.
        J Am Soc Echocardiogr. 2015; 28: 1-39.e14
        • Mosteller R.D.
        Simplified calculation of body-surface area.
        N Engl J Med. 1987; 317: 1098
        • Zoghbi W.A.
        • Adams D.
        • Bonow R.O.
        • Enriquez-Sarano M.
        • Foster E.
        • Grayburn P.A.
        • et al.
        Recommendations for noninvasive evaluation of native valvular regurgitation: a report from the American Society of Echocardiography developed in collaboration with the Society for Cardiovascular Magnetic Resonance.
        J Am Soc Echocardiogr. 2017; 30: 303-371
        • Rudski L.G.
        • Lai W.W.
        • Afilalo J.
        • Hua L.
        • Handschumacher M.D.
        • Chandrasekaran K.
        • et al.
        Guidelines for the echocardiographic assessment of the right heart in adults: a report from the American Society of Echocardiography endorsed by the European Association of Echocardiography, a registered branch of the European Society of Cardiology, and the Canadian Society of Echocardiography.
        J Am Soc Echocardiogr. 2010; 23: 685-713
        • Werner J.A.
        • Schiller N.B.
        • Prasquier R.
        Occurrence and significance of echocardiographically demonstrated tricuspid valve prolapse.
        Am Heart J. 1978; 96: 180-186
        • Weinreich D.J.
        • Burke J.F.
        • Bharati S.
        • Lev M.
        Isolated prolapse of the tricuspid valve.
        J Am Coll Cardiol. 1985; 6: 475-481
        • Schlamowitz R.A.
        • Gross S.
        • Keating E.
        • Pitt W.
        • Mazur J.
        Tricuspid valve prolapse: a common occurrence in the click-murmur syndrome.
        J Clin Ultrasound. 1982; 10: 435-439
        • Ogawa S.
        • Hayashi J.
        • Sasaki H.
        • Tani M.
        • Akaishi M.
        • Mitamura H.
        Evaluation of combined valvular prolapse syndrome by two-dimensional echocardiography.
        Circulation. 1982; 65: 174-180
        • Gooch A.S.
        • Maranhao V.
        • Scampardonis G.
        • Cha S.D.
        • Yang S.S.
        Prolapse of both mitral and tricuspid leaflets in systolic murmur-click syndrome.
        N Engl J Med. 1972; 287: 1218-1222
        • Pomerance A.
        Ballooning deformity (mucoid degeneration) of atrioventricular valves.
        Br Heart J. 1969; 31: 343-351
        • Ton-Nu T.T.
        • Levine R.A.
        • Handschumacher M.D.
        • Dorer D.J.
        • Yosefy C.
        • Fan D.
        • et al.
        Geometric determinants of functional tricuspid regurgitation: insights from 3-dimensional echocardiography.
        Circulation. 2006; 114: 143-149
        • Perazzolo Marra M.
        • Basso C.
        • De Lazzari M.
        • Rizzo S.
        • Cipriani A.
        • Giorgi B.
        • et al.
        Circ Cardiovasc Imaging. 2016; 9: e005030
        • Avierinos J.F.
        • Gersh B.J.
        • Melton III, L.J.
        • Bailey K.R.
        • Shub C.
        • Nishimura R.A.
        • et al.
        Natural history of asymptomatic mitral valve prolapse in the community.
        Circulation. 2002; 106: 1355-1361
        • Kolte D.
        • Lakshmanan S.
        • Jankowich M.D.
        • Brittain E.L.
        • Maron B.A.
        • Choudhary G.
        Mild pulmonary hypertension is associated with increased mortality: a systematic review and meta-analysis.
        J Am Heart Assoc. 2018; 7: e009729