Understanding tricuspid valve remodelling in atrial fibrillation using three-dimensional echocardiography

Abstract

<jats:title>Abstract</jats:title> <jats:sec> <jats:title>Aims</jats:title> <jats:p>Atrial fibrillation (AF) has been associated with tricuspid annulus (TA) dilation in patients with severe functional tricuspid regurgitation (TR); however, the impact of AF is less clear in patients without severe TR. Our aim was to characterize TA remodelling in patients with AF in the absence of severe TR using 3D transoesophageal echocardiography (TOE).</jats:p> </jats:sec> <jats:sec> <jats:title>Methods and results</jats:title> <jats:p>Ninety patients underwent clinically indicated transthoracic and TOE: non-structural (NS)-AF (n = 30); AF with left heart disease (LHD) (n = 30), and controls in sinus rhythm (n = 30). Three-dimensional TOE datasets were analysed to measure TA dimensions using novel dedicated tricuspid valve software. The NS-AF group showed biatrial dilatation and normal right ventricular (RV) size with decreased longitudinal function compared to controls, whereas the LHD-AF group showed biatrial dilatation, RV enlargement, decreased biventricular function, and higher systolic pulmonary artery pressure compared with the other groups. Indexed TA area, minimum diameter, maximum diameter, and total perimeter were significantly larger in the NS-AF group than in controls (measurements in end-diastole: 6.4 ± 1.1 vs. 5.0 ± 0.6 cm2/m2, 1.8 ± 0.3 vs. 1.6 ± 0.2 cm/m2, 2.1 ± 0.3 vs. 1.9 ± 0.2 cm/m2, and 6.6 ± 0.9 vs. 5.9 ± 0.7 cm/m2, respectively, all P &amp;lt; 0.05). There was no significant difference in any indexed TA parameter between AF groups. TA circularity index (ratio between minimum and maximal diameters) and TA fractional area change between end-diastole and end-systole were no different among the three groups.</jats:p> </jats:sec> <jats:sec> <jats:title>Conclusion</jats:title> <jats:p>AF is associated with right atrial and tricuspid annular remodelling independent of the presence of LHD in patients with intrinsically normal tricuspid leaflets without severe TR.</jats:p> </jats:sec>

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

“…However, they studied only patients with severe FTR, used a software package developed for the mitral valve to measure TV geometry in a single midsystolic time frame, and measured only the RAVmax using a single 2DE view. Our data are also concordant with recently reported findings by Ortiz-Leon et al 7 who showed that, in patients without severe FTR, AF was associated with RA and TA remodeling independently of the presence of left heart diseases and that the size of the TA correlated with RAVmax but not with RV volumes. We were able to assess the dynamic function of both the TA and RA, and we added significantly to the results of Utsunomiya et al 27 and Ortiz-Leon et al 7 by showing that the main determinants of FTR severity were the TA area at end diastole and RAVmin in a population including patients with mild, moderate, and severe FTR.…”

“…[2][3][4][5][6] Recent three-dimensional echocardiography (3DE) studies have added evidence about the link between RA remodeling and development of FTR in AF patients. Ortiz-Leon et al 7 reported RA and tricuspid annulus (TA) dilation in AF patients without severe FTR. Muraru et al 8 documented the direct links among RA remodeling, TA dilation, and development of FTR during AF, leading to the concept that AF may cause FTR by affecting the geometry of the TA through the remodeling of the RA.…”

Atrial functional tricuspid regurgitation: a novel and underappreciated clinical entity

“…The proposed model of atriogenic regurgitationtypically with long-standing persistent AF -implies a signifi cantly remodeled RA that promotes a mar-ked and progressive dilatation of TV annulus in the presence of no or minimal dilation of the RV 4,25 . TV annulus is considerably enlarged in AF patients, even with less than severe FTR, and independently of the presence of cardiac structural abnormalities, supporting that TA dilation is the direct consequence of AF itself, rather than the result of FTR 26 . Compared with ventricular FTR patients and for similar FTR severity, patients with atrial FTR had increased dimensions and posterior displacement of the TV annulus, larger RA, and smaller RV 6 .…”

“…When quantifying the right-chambers' sizes by 2D echocardiography (2DE), signifi cant underestimation may occur due to foreshortening or geometrical assumptions. The 3D-derived methods allow a more accurate and reliable measure of both the RV and the RA, which is one of the key prerequisites in differenti- reports show that cardioversion in atrial FTR with documented maintenance of sinus rhythm promotes TV annulus and RA reverse remodeling and may signifi cantly reduce the severity of FTR at follow-up 26,44,45 .…”

Biatrial volume ratio predicts low voltage areas in atrial fibrillation

“…In patients without heart failure, volume and pressure overload in the RA is mainly associated with pulmonary resistance, valvular disease, and RV dysfunction. [28][29][30] Although AF may contribute to RA dilation as well, 31 AF triggers from the RA are rare 32 and RA ablation in AF patients has not shown any benefit for outcomes. 33 In our study, RAV > LAV was higher in males and was not associated with LVAs.…”