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Echocardiography and Decision Making for Surgery

Acknowledgment The authors acknowledge the contributions of Dr. Laila A. Payvandi, who was the author of this chapter in the previous edition. The diagnosis and management of patients with infective endocarditis (IE) can be a challenging. Because of the wide spectrum of presentations seen in IE, the current diagnostic approach incorporates clinical, pathological, serologic, and echocardiographic criteria into a strategy that maintains both sensitivity and specificity…

Limitations and Technical Considerations in Infective Endocarditis

Guidelines recommend echocardiography as the imaging modality of choice in the diagnosis and management guidance in patients with suspected infective endocarditis (IE). , Although echocardiographic findings lead to definitive diagnosis in the majority of patients, atypical results or results of uncertain clinical significance are not rare. The diagnostic yield and limitations of transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) depend on several factors, including (1) image…

Echocardiography for Prediction of Cardioembolic Risk

Spectrum of Cardioembolism The heart and the aorta are the sources of cardioembolism to any organ. Major clinical presentations involve either acute neurologic dysfunction—transient ischemic attack (TIA) or stroke—or peripheral vascular disease (e.g., acute limb ischemia, splenic or renal infarcts). All cardioembolic causes of TIA or stroke may also cause acute limb ischemia or organ infarcts, with additional thromboembolic sources being thrombus and atheroma in the…

Infective Endocarditis: Role of Transthoracic Versus Transesophageal Echocardiography

Acknowledgments The authors gratefully acknowledge Susan Nord and Jennifer Pfaff for their editorial assistance and Brian Miller and Brian Schurrer for their help with the figures. We also thank Drs. Maria C. Todaro, Concetta Zito, and Scipione Carerj for their contributions to the previous edition of this chapter. Infective endocarditis (IE) is one of the most severe infectious diseases and is characterized by a poor prognosis…

Tricuspid and Pulmonic Prosthetic Valves

Various types of prosthetic heart valves (PHVs) have been available in clinical practice during the past five decades. Tricuspid valve replacement (TVR) is now an uncommon procedure and has been described in fewer than 2% of all valve operations in one study. Current guidelines recommend TVR is reasonable for severe tricuspid regurgitation (TR) secondary to diseased or abnormal tricuspid valve (TV) leaflets not amenable to annuloplasty…

Mitral Valve Repair

Perioperative echocardiographers should approach patients scheduled for mitral valve (MV) surgery with several goals and the intention of using these data to facilitate clinical and surgical decision making. It is therefore important to (1) establish the cause, mechanism, and severity of MV dysfunction; (2) determine the presence of any echocardiographic predictors of a difficult MV repair; (3) obtain relevant measurements of the MV apparatus to assist…

Mitral Prosthetic Valves

Acknowledgment The authors acknowledge the contributions of Dr. Hillier, who was the author of this chapter in the previous edition. Transthoracic echocardiography (TTE) is the essential imaging investigation for comprehensive baseline assessment and serial evaluation of mitral prosthetic valve function. It is important to understand the prosthetic valve design features to enhance interpretation of the anatomic and hemodynamic data. A standardized TTE protocol is essential in…

Aortic Prosthetic Valves

Acknowledgment We thank Dr. Damian Roper for his contributions to the earlier edition of this chapter. Transthoracic echocardiography (TTE) is established as the reference imaging modality for the routine evaluation of prosthetic valves because of the comprehensive anatomic, functional, and hemodynamic data obtained combined with its excellent safety profile. However, the unique acoustic properties of prosthetic valves can impair the echocardiographic examination, resulting in reduced diagnostic…

Classification of Prosthetic Valve Types and Fluid Dynamics

Acknowledgments The authors thank Drs. Jean G. Dumesnil and Haifa Mahjoub for their contributions to this chapter in the previous edition. More than 300,000 patients per year require valve replacement in the world, and this number is estimated to triple to more than 850,000 by 2050. The ideal valve substitute should mimic the characteristics of a normal native valve with excellent hemodynamics, long durability, high thromboresistance,…

Tricuspid and Pulmonic Stenosis

Tricuspid Stenosis Cause Tricuspid stenosis (TS) is the least common stenotic valvulopathy. TS is most commonly the result of rheumatic heart disease (RHD). Isolated involvement of the tricuspid valve (TV) is seen in congenital TS or in carcinoid heart disease. Other causes include metabolic or enzymatic abnormalities such as Fabry and Whipple disease. 1. Rheumatic TS. RHD, although infrequent in developed countries, accounts for the majority…

Pulmonic Regurgitation: Etiology and Quantification

Trivial or mild degrees of pulmonic regurgitation (PR) are common in structurally normal hearts, and the presence of pathologic PR is rare in adults. Some degree of PR is present in between 5% and 78% in echocardiograms of patients with normal pulmonic valves (PVs) and structurally normal hearts. Echocardiographic evaluation of the degree PR is much less well defined than for the other heart valves and…

Device Lead–Associated Tricuspid Regurgitation

According to the American Heart Association (AHA) heart disease and stroke statistics, in the year 2014, more than 300,000 pacemakers (PMs) and 60,000 intracardiac defibrillators (ICDs) were implanted in United States. As the population continues to age, the number of cardiac implantable electronic device (CIED) leads, which includes PMs, ICDs, and cardiac resynchronization therapy (CRT), will most likely increase. The first reports of device lead–mediated interference…

Imaging for Surgical and Percutaneous Tricuspid Valve Procedures

Tricuspid valve (TV) disease or dysfunction is classified as primary (i.e., intrinsic) valve pathology or secondary. , Secondary or functional tricuspid regurgitation (TR) is the most common cause of TR and represents an important unmet treatment need given its prevalence, adverse prognostic impact, and symptom burden associated with progressive right heart failure. , Indications for intervening on TR are dependent first on determining valve morphology (primary…

Indications for Tricuspid Valve Intervention

Tricuspid valve (TV) surgery has one of the highest morbidity and mortality rates of all cardiac surgical procedures. , This is not necessarily because TV repair (TVr) or TV replacement (TVR) is particularly difficult technically, but rather because the presence of tricuspid regurgitation (TR) often reflects advanced cardiac disease, right ventricular (RV) dysfunction, chronic heart failure, and generally poor functional state. The evolution of two- and…

Quantification of Tricuspid Regurgitation

Two- and three-dimensional echocardiography (2DE and 3DE, respectively), combined with spectral and color-flow Doppler evaluation, provides the most accurate laboratory test in detection and quantification of tricuspid regurgitation (TR). “Physiologic” TR is associated with normal valve leaflet morphology and normal right ventricular and atrial size ( Fig. 103.1 ). When “pathologic” TR is suspected on color Doppler, a complete understanding of leaflet morphology and of the…

Epidemiology, Etiology, and Natural History of Tricuspid Regurgitation

Tricuspid regurgitation (TR) is characterized by a variable amount of blood regurgitating from the right ventricle (RV) into the right atrium (RA) during systole, eventually leading to excess mortality and cardiac morbidity. Several studies showed that the prevalence of clinically significant (i.e., moderate or severe) TR in the general population is around 0.5% to 0.8% and is more common in women and older adults. , Although…

Tricuspid Valve Complex: Anatomy by Two-Dimensional and Three-Dimensional Echocardiography

Tricuspid Valve Anatomy The tricuspid valve (TV) is the largest of the four cardiac valves, with a normal valve area of 7 to 9 cm 2 . The TV lies between the right atrium and the right ventricle and is placed in a more apical position than the mitral valve. The TV functional anatomy can be divided into four components: the leaflets, annulus (with attached right…

Role of Exercise Stress Testing in Mitral Regurgitation

Mitral regurgitation (MR) is a load-dependent valvular disease, and its increase in severity during exercise has been reported irrespective of cause. The evaluation of MR limited to resting conditions risks may underestimate the full clinical impact of the lesion. Exercise stress testing (EST) can be a useful tool to identify the dynamic nature of MR. Indeed, EST is recommended by the guidelines on the management of…

Asymptomatic Severe Mitral Regurgitation

Mitral regurgitation (MR) may result from primary abnormalities of the mitral valve (MV) apparatus (primary or degenerative MR) or from left ventricular (LV) dysfunction and remodeling (functional or secondary MR). The current American College of Cardiology (ACC)/American Heart Association (AHA) guidelines recommend surgery in symptomatic patients with chronic severe MR; ACC/AHA stage D in all patients with primary (degenerative) MR and only in selected patients with…

Quantification of Mitral Regurgitation

Mitral regurgitation (MR) is the most common valvular disease in the developed world and is expected to increase with the aging population. Primary MR is caused by an intrinsic valve abnormality (usually degenerative mitral valve [MV] disease), whereas secondary (functional) MR occurs in the setting of left ventricular (LV) remodeling, mitral annular dilatation, or both. Numerous studies have shown that untreated, severe MR is associated with…