Table 1 Role of intraoperative transoesophageal echocardiography in assessment and management of severe tricuspid regurgitation during liver transplantation
Exclude structural TR | 2D imaging | • Normal appearance and motion of tricuspid valve leaflets and para-annular structures |
Exclude severe functional tricuspid regurgitation | Colour flow doppler | • Jet area > 10 cm2 • Large proximal flow convergence • Vena contracta width > 0.7 cm |
Spectral doppler | • Systolic flow reversal in hepatic veins • Dense TR signal with short deceleration time • Tricuspid inflow E wave > 1 cm/s • Effective Regurgitant Orifice Area > 0.4 cm2 • Regurgitant Volume > 45 ml | |
Assess RV systolic function | • RV fractional area change • TAPSE • RV systolic myocardial velocity | |
Assess degree of RV and tricuspid annular dilatation | • RV End Diastolic Area • RV End Diastolic diameter (basal, mid, apical) • Tricuspid Annulus Diameter | |
Assist quantification of left heart disease driving PHT | • Estimate LAP (LA size, inter-atrial septum mobility, E/e’) • Assess LV diastolic and systolic function • Quantify severity of mitral regurgitation/ stenosis | |
Monitor improvement in the above indices in response to interventions reducing: | • RV preload (eg. systemic venous blood volume; positioning) • RV afterload (eg. pulmonary vascular blood volume; pulmonary vascular resistance; interventions to improve LAP) | |