Right atrial volume is a major determinant of tricuspid annulus area in functional tricuspid regurgitation: a three-dimensional echocardiographic study

Abstract

Aims The aim of this study is to explore the relationships of tricuspid annulus area (TAA) with right atrial maximal volume (RAVmax) and right ventricular end-diastolic volume (RVEDV) in healthy subjects and patients with functional tricuspid regurgitation (FTR) of different aetiologies and severities. Methods and results We enrolled 280 patients (median age 66 years, 59% women) with FTR due to left heart disease (LHD), pulmonary hypertension (PH), corrected tetralogy of Fallot (TOF), chronic atrial fibrillation (AF), and 210 healthy volunteers (45 years, 53% women). We measured TAA at mid-systole and end-diastole, tenting volume of tricuspid leaflets, RAVmax, and RVEDV by 3D echocardiography. Irrespective of TA measurement timing, TAA correlated more closely with RAVmax than with RVEDV in both controls and FTR patients. On multivariable analysis, RAVmax was the most important determinant of TAA, accounting for 41% (normals) and 56% (FTR) of TAA variance. In FTR patients, age, RVEDV, and left ventricular ejection fraction were also independently correlated with TAA. RAVmax (AUC = 0.81) and TAA (AUC = 0.78) had a greater ability than RVEDV (AUC = 0.72) to predict severe FTR (P < 0.05). Among FTR patients, those with AF had the largest RAVmax and smallest RVEDV. RAVmax and TA were significantly dilated in all FTR groups, except in TOF. PH and TOF had largest RVEDV, yet tenting volume was increased only in PH and LHD. Conclusion RA volume is a major determinant of TAA, and RA enlargement is an important mechanism of TA dilation in FTR irrespective of cardiac rhythm and RV loading conditions.

Geometrical remodeling of the mitral and tricuspid annuli in response to exercise training: a 3-D echocardiographic study in elite athletes

“…Notably, however, atrial volumes were independent determinants of annular areas, whereas ventricular volumes were not. These results resonate with recent publications showing that the RA dilation is the major determinant of TA size in patients with atrial fibrillation and/or functional TR (20,21). Longitudinal studies with long-term follow-up are required to establish the (patho)physiological link between exercise-induced cardiac remodeling, functional valvular regurgitation, and, eventually, occurrence of atrial fibrillation.…”

The Pathophysiological Link between Right Atrial Remodeling and Functional Tricuspid Regurgitation in Patients with Atrial Fibrillation: A Three-Dimensional Echocardiography Study

“…5 The role of the remodeling of the right heart structures associated with lone AF in determining FTR has already been the topic of several studies. Recently, Muraru et al 15 have demonstrated the major role of the RA in determining TA size in different conditions affecting the right heart, and the direct pathophysiological link between AF, RA remodeling, and TA enlargement as a cause of FTR in a few patients with persistent AF who underwent HIGHLIGHTS Three-dimensional echocardiography is key to assess TV and right heart chamber geometry. Tricuspid annulus area is more strictly correlated with RA than ventricular size.…”

Atrial functional tricuspid regurgitation: a novel and underappreciated clinical entity

“…It occurs with changes in RV geometry and function due to volume and/or pressure overload, such as an increase in RV volume, RV global or regional systolic dysfunction or shape abnormalities (increased sphericity, abnormal regional curvature, etc.) 3,23 . Annular dilatation is an important contributor to the development of ventricular FTR, leading to edge-to-edge leafl et coaptation 20 .…”

“…The importance of the RA has been ignored, despite the close anatomic relationship of the RA vestibule with the TV annulus. The RA vestibule is a smooth muscular rim that anchors the pectinate muscles and surrounds the TV orifi ce, with its thin musculature fibers inserting into the leafl et hinges 3 . In contrast with the MV annulus, which is disconnected from the left atrial myocardium between both fi brous trigones at the base of the anterior leafl et, the TV annulus has a single right fi brous trigone keeping it in closer contact with RA myocardium over a larger part of its circumference.…”

“…Recent evidence suggests that the RA is important not only in AF patients but also in sinus rhythm. Indeed, RA could be a major player in the development of FTR and a key determinant of TV annular dilation 32 , irrespective of its cause 3 . We demonstrated that in all FTR groups (including atrial form due to AF and ventricular form due to both RV pressure and volume overload), as well as in healthy subjects, the TA area was more closely related to RA volume than to RV end-diastolic volume measured by 3DE 3 .…”