title: Leaflet area as a determinant of tricuspid regurgitation severity in patients with pulmonary hypertension.
abstract: BACKGROUND
  Tricuspid regurgitation (TR) is a risk factor for mortality in pulmonary hypertension (PH). TR severity varies among patients with comparable degrees of PH and right ventricular remodeling. The contribution of leaflet adaptation to the pathophysiology of TR has yet to be examined. We hypothesized that tricuspid leaflet area (TLA) is increased in PH, and that the adequacy of this increase relative to right ventricular remodeling determines TR severity.
  
  
  RESULTS
  A prospective cohort of 255 patients with PH from pre and postcapillary pathogeneses was assembled from 2 centers. Patients underwent a 3-dimensional echocardiogram focused on the tricuspid apparatus. TLA was measured with the Omni 4D software package. Compared with normal controls, patients with PH had a 2-fold increase in right ventricular volumes, 62% increase in annular area, and 49% increase in TLA. Those with severe TR demonstrated inadequate increase in TLA relative to the closure area, such that the ratio of TLA:closure area <1.78 was highly predictive of severe TR (odds ratio, 68.7; 95% confidence interval, 16.2-292.7). The median vena contracta width was 8.5 mm in the group with small TLA and large closure area as opposed to 4.8 mm in the group with large TLA and large closure area.
  
  
  CONCLUSIONS
  TLA plays a significant role in determining which patients with PH develop severe functional TR. The ratio of TLA:closure area, reflecting the balance between leaflet adaptation versus annular dilation and tethering forces, is an indicator of TR severity that may identify which patients stand to benefit from leaflet augmentation during tricuspid valve repair.
authors.affiliation: From the Division of Cardiology, Jewish General Hospital, McGill University, Montreal, Canada (J.A., D.L., L.G.R.); Cardiac Ultrasound Laboratory, Division of Cardiology (J.G., P.N.) and National Pulmonary Hypertension Service, Division of Cardiology (J.S.R.G.), Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom; Pulmonary Hypertension and Thromboendarterectomy Program, Division of Pulmonary and Critical Care Medicine (R.N.C.) and Cardiac Ultrasound Laboratory, Division of Cardiology (J.A., J.B., L.H., M.D.H., M.H.P., R.A.L.), Massachusetts General Hospital, Harvard University, Boston. jonathan.afilalo@mcgill.ca.
authors.forename: Jonathan
authors.initials: J
authors.lastname: Afilalo
authors.affiliation: From the Division of Cardiology, Jewish General Hospital, McGill University, Montreal, Canada (J.A., D.L., L.G.R.); Cardiac Ultrasound Laboratory, Division of Cardiology (J.G., P.N.) and National Pulmonary Hypertension Service, Division of Cardiology (J.S.R.G.), Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom; Pulmonary Hypertension and Thromboendarterectomy Program, Division of Pulmonary and Critical Care Medicine (R.N.C.) and Cardiac Ultrasound Laboratory, Division of Cardiology (J.A., J.B., L.H., M.D.H., M.H.P., R.A.L.), Massachusetts General Hospital, Harvard University, Boston.
authors.forename: Julia
authors.initials: J
authors.lastname: Grapsa
authors.affiliation: From the Division of Cardiology, Jewish General Hospital, McGill University, Montreal, Canada (J.A., D.L., L.G.R.); Cardiac Ultrasound Laboratory, Division of Cardiology (J.G., P.N.) and National Pulmonary Hypertension Service, Division of Cardiology (J.S.R.G.), Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom; Pulmonary Hypertension and Thromboendarterectomy Program, Division of Pulmonary and Critical Care Medicine (R.N.C.) and Cardiac Ultrasound Laboratory, Division of Cardiology (J.A., J.B., L.H., M.D.H., M.H.P., R.A.L.), Massachusetts General Hospital, Harvard University, Boston.
authors.forename: Petros
authors.initials: P
authors.lastname: Nihoyannopoulos
authors.affiliation: From the Division of Cardiology, Jewish General Hospital, McGill University, Montreal, Canada (J.A., D.L., L.G.R.); Cardiac Ultrasound Laboratory, Division of Cardiology (J.G., P.N.) and National Pulmonary Hypertension Service, Division of Cardiology (J.S.R.G.), Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom; Pulmonary Hypertension and Thromboendarterectomy Program, Division of Pulmonary and Critical Care Medicine (R.N.C.) and Cardiac Ultrasound Laboratory, Division of Cardiology (J.A., J.B., L.H., M.D.H., M.H.P., R.A.L.), Massachusetts General Hospital, Harvard University, Boston.
authors.forename: Jonathan
authors.initials: J
authors.lastname: Beaudoin
authors.affiliation: From the Division of Cardiology, Jewish General Hospital, McGill University, Montreal, Canada (J.A., D.L., L.G.R.); Cardiac Ultrasound Laboratory, Division of Cardiology (J.G., P.N.) and National Pulmonary Hypertension Service, Division of Cardiology (J.S.R.G.), Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom; Pulmonary Hypertension and Thromboendarterectomy Program, Division of Pulmonary and Critical Care Medicine (R.N.C.) and Cardiac Ultrasound Laboratory, Division of Cardiology (J.A., J.B., L.H., M.D.H., M.H.P., R.A.L.), Massachusetts General Hospital, Harvard University, Boston.
authors.forename: J Simon R
authors.initials: JS
authors.lastname: Gibbs
authors.affiliation: From the Division of Cardiology, Jewish General Hospital, McGill University, Montreal, Canada (J.A., D.L., L.G.R.); Cardiac Ultrasound Laboratory, Division of Cardiology (J.G., P.N.) and National Pulmonary Hypertension Service, Division of Cardiology (J.S.R.G.), Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom; Pulmonary Hypertension and Thromboendarterectomy Program, Division of Pulmonary and Critical Care Medicine (R.N.C.) and Cardiac Ultrasound Laboratory, Division of Cardiology (J.A., J.B., L.H., M.D.H., M.H.P., R.A.L.), Massachusetts General Hospital, Harvard University, Boston.
authors.forename: Richard N
authors.initials: RN
authors.lastname: Channick
authors.affiliation: From the Division of Cardiology, Jewish General Hospital, McGill University, Montreal, Canada (J.A., D.L., L.G.R.); Cardiac Ultrasound Laboratory, Division of Cardiology (J.G., P.N.) and National Pulmonary Hypertension Service, Division of Cardiology (J.S.R.G.), Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom; Pulmonary Hypertension and Thromboendarterectomy Program, Division of Pulmonary and Critical Care Medicine (R.N.C.) and Cardiac Ultrasound Laboratory, Division of Cardiology (J.A., J.B., L.H., M.D.H., M.H.P., R.A.L.), Massachusetts General Hospital, Harvard University, Boston.
authors.forename: David
authors.initials: D
authors.lastname: Langleben
authors.affiliation: From the Division of Cardiology, Jewish General Hospital, McGill University, Montreal, Canada (J.A., D.L., L.G.R.); Cardiac Ultrasound Laboratory, Division of Cardiology (J.G., P.N.) and National Pulmonary Hypertension Service, Division of Cardiology (J.S.R.G.), Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom; Pulmonary Hypertension and Thromboendarterectomy Program, Division of Pulmonary and Critical Care Medicine (R.N.C.) and Cardiac Ultrasound Laboratory, Division of Cardiology (J.A., J.B., L.H., M.D.H., M.H.P., R.A.L.), Massachusetts General Hospital, Harvard University, Boston.
authors.forename: Lawrence G
authors.initials: LG
authors.lastname: Rudski
authors.affiliation: From the Division of Cardiology, Jewish General Hospital, McGill University, Montreal, Canada (J.A., D.L., L.G.R.); Cardiac Ultrasound Laboratory, Division of Cardiology (J.G., P.N.) and National Pulmonary Hypertension Service, Division of Cardiology (J.S.R.G.), Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom; Pulmonary Hypertension and Thromboendarterectomy Program, Division of Pulmonary and Critical Care Medicine (R.N.C.) and Cardiac Ultrasound Laboratory, Division of Cardiology (J.A., J.B., L.H., M.D.H., M.H.P., R.A.L.), Massachusetts General Hospital, Harvard University, Boston.
authors.forename: Lanqi
authors.initials: L
authors.lastname: Hua
authors.affiliation: From the Division of Cardiology, Jewish General Hospital, McGill University, Montreal, Canada (J.A., D.L., L.G.R.); Cardiac Ultrasound Laboratory, Division of Cardiology (J.G., P.N.) and National Pulmonary Hypertension Service, Division of Cardiology (J.S.R.G.), Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom; Pulmonary Hypertension and Thromboendarterectomy Program, Division of Pulmonary and Critical Care Medicine (R.N.C.) and Cardiac Ultrasound Laboratory, Division of Cardiology (J.A., J.B., L.H., M.D.H., M.H.P., R.A.L.), Massachusetts General Hospital, Harvard University, Boston.
authors.forename: Mark D
authors.initials: MD
authors.lastname: Handschumacher
authors.affiliation: From the Division of Cardiology, Jewish General Hospital, McGill University, Montreal, Canada (J.A., D.L., L.G.R.); Cardiac Ultrasound Laboratory, Division of Cardiology (J.G., P.N.) and National Pulmonary Hypertension Service, Division of Cardiology (J.S.R.G.), Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom; Pulmonary Hypertension and Thromboendarterectomy Program, Division of Pulmonary and Critical Care Medicine (R.N.C.) and Cardiac Ultrasound Laboratory, Division of Cardiology (J.A., J.B., L.H., M.D.H., M.H.P., R.A.L.), Massachusetts General Hospital, Harvard University, Boston.
authors.forename: Michael H
authors.initials: MH
authors.lastname: Picard
authors.affiliation: From the Division of Cardiology, Jewish General Hospital, McGill University, Montreal, Canada (J.A., D.L., L.G.R.); Cardiac Ultrasound Laboratory, Division of Cardiology (J.G., P.N.) and National Pulmonary Hypertension Service, Division of Cardiology (J.S.R.G.), Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom; Pulmonary Hypertension and Thromboendarterectomy Program, Division of Pulmonary and Critical Care Medicine (R.N.C.) and Cardiac Ultrasound Laboratory, Division of Cardiology (J.A., J.B., L.H., M.D.H., M.H.P., R.A.L.), Massachusetts General Hospital, Harvard University, Boston.
authors.forename: Robert A
authors.initials: RA
authors.lastname: Levine
mesh_terms: D000328:Adult; D016022:Case-Control Studies; D019560:Echocardiography, Three-Dimensional; D005260:Female; D006801:Humans; D006976:Hypertension, Pulmonary / Q000000981:diagnostic imaging / Q000503:physiopathology*; D007090:Image Interpretation, Computer-Assisted; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D012307:Risk Factors; D012720:Severity of Illness Index; D012984:Software; D014262:Tricuspid Valve Insufficiency / Q000000981:diagnostic imaging / Q000503:physiopathology*; D020257:Ventricular Remodeling
keywords: echocardiography; pulmonary hypertension; tricuspid regurgitation